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NPI Code Detail

MEDICARE: CENTRA MEDICAL GROUP, LLC

MEDICARE: CENTRA MEDICAL GROUP, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QR1300XRural Health Clinic/Center

General Provider Information

NPI Number : 1164720058
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTRA MEDICAL GROUP, LLC
Provider Business Mailing Address
First Line : 1204 FENWICK DR
Second Line :
City : LYNCHBURG
State : VA
Zip : 24502-2112
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1280A MAIN ST
Second Line :
City : ALTAVISTA
State : VA
Zip : 24517-1465
Country : US
Telephone Number : 434-309-1165
Fax Number :
Authorized Official
Title or Position : SR VP, CFO
Name : LEWIS ADDISON
Credential :
Telephone Number : 434-200-3656
Provider Enumeration Date : 03/02/2011
Last Update Date : 11/14/2012

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