Healthcare Provider Details

I. General information

NPI: 1285931089
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 AIRPORT DR SUITE A
DANVILLE VA
24540-5196
US

IV. Provider business mailing address

1204 FENWICK DR
LYNCHBURG VA
24502-2112
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-2612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEWIS ADDISON
Title or Position: CFO
Credential:
Phone: 434-200-3656