MEDICARE: 1212 MED PLLC

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	:	1982470100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1212 MED PLLC

Provider Business Mailing Address
First Line	:	674 LEES GAP RD
Second Line	:
City	:	FINCASTLE
State	:	VA
Zip	:	24090-3869
Country	:	US
Telephone Number	:	540-682-3082
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 E LABURNUM AVE STE 3
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2134
Country	:	US
Telephone Number	:	540-200-8821
Fax Number	:	540-779-7889

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HENRY BURGESS
Credential	:	MD
Telephone Number	:	540-682-3082

Provider Enumeration Date	:	11/29/2023
Last Update Date	:	03/07/2024

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