1841479565 NPI number — CENTRA MEDICAL GROUP SOUTHSIDE, LLC

Table of content: (NPI 1841479565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841479565 NPI number — CENTRA MEDICAL GROUP SOUTHSIDE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRA MEDICAL GROUP SOUTHSIDE, LLC
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:
1841479565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 ATHERHOLT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24501-1106
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:
800 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901-1199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-200-3656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BASS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
434-392-8811

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 345608 . This is a "ANTHEM BCBS (312 KING STREET)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 61459600 . This is a "BLACK LUNG/FECA (STE 3105)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 61459602 . This is a "BLACK LUNG/FECA (412 NAMOZINE STR)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 61459604 . This is a "BLACK LUNG/FECA (1418 6TH ST)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 345604 . This is a "ANTHEM BCBS (800 OAK STREET)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 345307 . This is a "ANTHEM, BCBS (1418 6TH STREET)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 345606 . This is a "ANTHEM BCBS (412 NAMOZINE STREET)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 61459601 . This is a "BLACK LUNG/FECA (312 KING ST)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 61459603 . This is a "BLACK LUNG/FECA (1705 3RD ST)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1841479565 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9978134 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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