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NPI Code Detail

MEDICARE: MEDITELECARE OF VIRGINIA, LLC

MEDICARE: MEDITELECARE 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
1104100000XSocial Worker
22084P0800XPsychiatry Physician
32084P0805XGeriatric Psychiatry Physician
4363LP0808XPsychiatric/Mental Health Nurse Practitioner
5103TC0700XClinical Psychologist

General Provider Information

NPI Number : 1851890321
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDITELECARE OF VIRGINIA, LLC
Provider Business Mailing Address
First Line : PO BOX 1595
Second Line :
City : MIDDLETOWN
State : CT
Zip : 06457-8095
Country : US
Telephone Number : 860-788-6404
Fax Number : 860-829-0495
Provider Business Practice Location Address
First Line : 4701 COX RD STE 285
Second Line :
City : GLEN ALLEN
State : VA
Zip : 23060-6808
Country : US
Telephone Number : 860-788-6404
Fax Number :
Authorized Official
Title or Position : CREDENT AND ENROLLMENT MANAGER
Name : ANDREA GODFREY
Credential :
Telephone Number : 860-398-6441
Provider Enumeration Date : 02/09/2018
Last Update Date : 05/05/2025

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