1275690976 NPI number — VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY

Table of content: (NPI 1275690976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275690976 NPI number — VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY
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:
VTCC-RESIDENTAL TREATMENT
Provider Other Organization Name Type Code:
3
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:
1275690976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 758997
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1308 SHERWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-628-6643
Provider Business Practice Location Address Fax Number:
804-828-2029
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HANCOCK
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
804-212-5145

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  H1875 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 207063 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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