MEDICARE: ORTHOVIRGINIA 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	207X00000X	Orthopaedic Surgery Physician
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	0102204066	VA
3	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1932638921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOVIRGINIA INC

Provider Business Mailing Address
First Line	:	PO BOX 715868
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19171-5868
Country	:	US
Telephone Number	:	804-915-1910
Fax Number	:	804-560-9029

Provider Business Practice Location Address
First Line	:	590 W RIDGE RD STE K
Second Line	:
City	:	WYTHEVILLE
State	:	VA
Zip	:	24382-1067
Country	:	US
Telephone Number	:	540-442-7133
Fax Number	:	540-552-7143

Authorized Official
Title or Position	:	CREDENTIALING & ENROLLMENT
Name	:	NICOLE PROFFITT
Credential	:
Telephone Number	:	804-533-2357

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	06/10/2024

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