MEDICARE: CENTRA HEALTH PROFESSIONAL SERVICES, 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1619912441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRA HEALTH PROFESSIONAL SERVICES, 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	:	24517-1458
Country	:	US
Telephone Number	:	434-309-1165
Fax Number	:

Authorized Official
Title or Position	:	VP PHYSICIAN PRACTICE MANAGEMENT
Name	:	ARTHUR LEAVITT
Credential	:
Telephone Number	:	434-200-3656

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	04/25/2012

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