Healthcare Provider Details

I. General information

NPI: 1942630397
Provider Name (Legal Business Name): PEDIATRIC PARTNERS OF VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5207 HICKORY PARK DR STE C
GLEN ALLEN VA
23059-2624
US

IV. Provider business mailing address

5207 HICKORY PARK DR STE C
GLEN ALLEN VA
23059-2624
US

V. Phone/Fax

Practice location:
  • Phone: 804-377-8981
  • Fax: 804-377-8984
Mailing address:
  • Phone: 804-377-8981
  • Fax: 804-377-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101051967
License Number StateVA

VIII. Authorized Official

Name: DAVID SUTHERLAND
Title or Position: ADMINISTRATOR
Credential:
Phone: 804-363-0270