Healthcare Provider Details

I. General information

NPI: 1841649068
Provider Name (Legal Business Name): ORTHOVIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S MAIN ST SUITE 224A
BLACKSBURG VA
24060
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-4067
US

V. Phone/Fax

Practice location:
  • Phone: 540-552-7133
  • Fax: 540-342-2193
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-560-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0102204066
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: NICOLE PROFFITT
Title or Position: CREDENTIALING & ENROLLMENT
Credential:
Phone: 804-533-2357