1225118532 NPI number — PEDIATRIC PRIMARY CARE, PC

Table of content: (NPI 1225118532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225118532 NPI number — PEDIATRIC PRIMARY CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PRIMARY CARE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225118532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 POCOSHOCK PL
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23235-6345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-674-1985
Provider Business Mailing Address Fax Number:
804-276-1048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 POCOSHOCK PL
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23235-6345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-674-1985
Provider Business Practice Location Address Fax Number:
804-276-1048
Provider Enumeration Date:
10/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PILLSBURY DAVID
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-674-1985

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1764809 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 231001 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 111185 . This is a "OPTIMA HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".