Healthcare Provider Details

I. General information

NPI: 1043725336
Provider Name (Legal Business Name): M CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 ALBEMARLE SQUARE
CHARLOTTESVILLE VA
22901
US

IV. Provider business mailing address

406 ALBEMARLE SQUARE
CHARLOTTESVILLE VA
22901
US

V. Phone/Fax

Practice location:
  • Phone: 434-321-5257
  • Fax: 434-321-5259
Mailing address:
  • Phone: 434-321-5257
  • Fax: 434-321-5259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101239018
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number0101239018
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024166491
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101239018
License Number StateVA

VIII. Authorized Official

Name: ZACHARY BUSH
Title or Position: DIRECTOR OF CLINICAL AFFAIRS
Credential: M.D.
Phone: 434-321-5257