Healthcare Provider Details

I. General information

NPI: 1629266812
Provider Name (Legal Business Name): PEDIATRIC PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CONCOURSE BLVD SUITE 111
GLEN ALLEN VA
23059-5642
US

IV. Provider business mailing address

100 CONCOURSE BLVD SUITE 111
GLEN ALLEN VA
23059-5642
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 Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateVA

VIII. Authorized Official

Name: JILL E RYLAND
Title or Position: OWNER
Credential: M.D.
Phone: 804-377-8981