MEDICARE: VIRGINIA BREAST CENTER 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	208600000X	Surgery Physician	0101045452	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982688818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA BREAST CENTER INC

Provider Business Mailing Address
First Line	:	13700 SAINT FRANCIS BLVD
Second Line	:	STE 510
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-3267
Country	:	US
Telephone Number	:	804-594-3130
Fax Number	:	804-594-3130

Provider Business Practice Location Address
First Line	:	13700 SAINT FRANCIS BLVD
Second Line	:	STE 510
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-3267
Country	:	US
Telephone Number	:	804-594-3130
Fax Number	:	804-594-3130

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES V PELLICANE JR.
Credential	:	M.D.
Telephone Number	:	804-594-3130

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	08/22/2020

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