Healthcare Provider Details

I. General information

NPI: 1477091247
Provider Name (Legal Business Name): VIRGINIA CENTER FOR ADDICTION MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 PARK PLACE CT
GLEN ALLEN VA
23060-3314
US

IV. Provider business mailing address

4212 PARK PLACE CT
GLEN ALLEN VA
23060-3314
US

V. Phone/Fax

Practice location:
  • Phone: 804-332-5950
  • Fax: 804-728-1086
Mailing address:
  • Phone: 804-332-5950
  • Fax: 804-728-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number0101015030
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number0101246355
License Number StateVA

VIII. Authorized Official

Name: JAMES EDWARD THOMPSON
Title or Position: CMO
Credential: M.D.
Phone: 804-332-5950