Healthcare Provider Details

I. General information

NPI: 1639709769
Provider Name (Legal Business Name): PATHWAY HEALTHCARE-VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 NEELEY RD
BIG STONE GAP VA
24219-4474
US

IV. Provider business mailing address

1000 URBAN CENTER DR STE 600
VESTAVIA AL
35242-2584
US

V. Phone/Fax

Practice location:
  • Phone: 703-544-7861
  • Fax:
Mailing address:
  • Phone: 205-208-9312
  • Fax: 205-848-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA COX
Title or Position: CREDENTIALING
Credential:
Phone: 205-208-9312