Basic Information
| Provider Information | |||||||||
| NPI: | 1992864763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOVIRGINIA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045605595 | ||||||||
| FaxNumber: | 8045609029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1849 OLD DONATION PKWY | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574228476 | ||||||||
| FaxNumber: | 7572134332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/23/2019 | ||||||||
| NPIReactivationDate: | 04/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8049154600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 0101043878 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.