1548260912 NPI number — LAURA KELLAM PRATT MD

Table of content: LAURA KELLAM PRATT MD (NPI 1548260912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548260912 NPI number — LAURA KELLAM PRATT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATT
Provider First Name:
LAURA
Provider Middle Name:
KELLAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLAM
Provider Other First Name:
LAURA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548260912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 CONCOURSE BLVD
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23059-5643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-549-4030
Provider Business Mailing Address Fax Number:
804-549-4032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 CHARLES DIMMOCK PKWY
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
COLONIAL HEIGHTS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23834-2940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-526-7364
Provider Business Practice Location Address Fax Number:
804-526-7394
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  0101231692 , 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: P00047267 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7442479 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010008280 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0300585 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 230056 . This is a "SOUTHERN HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 465745 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com