Basic Information
Provider Information | |||||||||
NPI: | 1972680049 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BLUE RIDGE IMMEDIATE CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2489 | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 245516489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4343821139 | ||||||||
FaxNumber: | 4345255748 | ||||||||
Practice Location | |||||||||
Address1: | 2137 LAKESIDE DR | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245016803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4343854184 | ||||||||
FaxNumber: | 4343850381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 03/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAYNES | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | STAFF CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4343821139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL VIRGINIA FAMILY PHYSICIANS, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1528155892 | 01 | VA | CVFP CORPORATE NPI | OTHER | 1528155892 | 05 | VA |   | MEDICAID | CA2436 | 01 | VA | MEDICARE RAILROAD | OTHER | CO3658 | 01 | VA | CVFP MCARE GROUP PTAN | OTHER |