Healthcare Provider Details

I. General information

NPI: 1588782569
Provider Name (Legal Business Name): HEALTHLINE FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13121 RIVERS BEND BLVD
CHESTER VA
23836-8624
US

IV. Provider business mailing address

13121 RIVERS BEND BLVD
CHESTER VA
23836-8624
US

V. Phone/Fax

Practice location:
  • Phone: 804-530-0707
  • Fax: 804-530-0074
Mailing address:
  • Phone: 804-530-0707
  • Fax: 804-530-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: MR. TUSHAR SHAH
Title or Position: PRESIDENT
Credential: MD
Phone: 804-530-0707