Healthcare Provider Details

I. General information

NPI: 1891102158
Provider Name (Legal Business Name): PRIMECARE PEDSXPRESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 SALEM CHURCH RD
FREDERICKSBURG VA
22407-6466
US

IV. Provider business mailing address

2511 SALEM CHURCH RD
FREDERICKSBURG VA
22407-6466
US

V. Phone/Fax

Practice location:
  • Phone: 540-786-1200
  • Fax: 540-786-3195
Mailing address:
  • Phone: 540-786-1200
  • Fax: 540-786-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANA P TATE
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 540-371-4488