MEDICARE: CHICKAHOMINY FAMILY PRACTICE, INC

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	0024168551	VA

General Provider Information

NPI Number	:	1669701249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICKAHOMINY FAMILY PRACTICE, INC

Provider Business Mailing Address
First Line	:	1414 N 22ND ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5152
Country	:	US
Telephone Number	:	804-683-6959
Fax Number	:

Provider Business Practice Location Address
First Line	:	2660 NEW MARKET RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-7408
Country	:	US
Telephone Number	:	804-795-1144
Fax Number	:	804-795-1052

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	JOHN P KOWALSKI
Credential	:	M.D.
Telephone Number	:	804-795-1144

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	12/10/2009

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