Healthcare Provider Details

I. General information

NPI: 1174971451
Provider Name (Legal Business Name): FORK UNION FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4064 JAMES MADISON HIGHWAY
FORK UNION VA
23055
US

IV. Provider business mailing address

PO BOX 696
FORK UNION VA
23055-0696
US

V. Phone/Fax

Practice location:
  • Phone: 434-842-3244
  • Fax: 434-842-1110
Mailing address:
  • Phone: 434-842-3244
  • Fax: 434-842-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101233552
License Number StateVA

VIII. Authorized Official

Name: MR. RAYMOND OSCAR BISHOP
Title or Position: OWNER
Credential: MD
Phone: 606-213-7895