MEDICARE: NEUROLOGY CENTER OF VIRGINIA, 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
1	174400000X	Specialist

General Provider Information

NPI Number	:	1194983569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROLOGY CENTER OF VIRGINIA, LLC

Provider Business Mailing Address
First Line	:	16718 KIPPER TURN
Second Line	:
City	:	MOSELEY
State	:	VA
Zip	:	23120-2222
Country	:	US
Telephone Number	:	804-302-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2436 COLONY CROSSING PL
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4281
Country	:	US
Telephone Number	:	804-302-4400
Fax Number	:	804-601-2515

Authorized Official
Title or Position	:	NEUROLOGIST/MEMBER
Name	:	DR. HERNAN TAPIA GATUSLAO JR.
Credential	:	M.D.
Telephone Number	:	804-302-4400

Provider Enumeration Date	:	06/01/2008
Last Update Date	:	04/27/2012

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