Healthcare Provider Details

I. General information

NPI: 1215940507
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP, INC., D/B/A COURTHOUSE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8264 GEORGE WASHINGTON MEMORIAL HWY
GLOUCESTER VA
23061-4127
US

IV. Provider business mailing address

PO BOX 800
GLOUCESTER VA
23061-0800
US

V. Phone/Fax

Practice location:
  • Phone: 804-695-0305
  • Fax: 804-695-0804
Mailing address:
  • Phone: 804-695-0305
  • Fax: 804-695-0804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101026966
License Number StateVA

VIII. Authorized Official

Name: KATHRYN J ABSHIRE
Title or Position: SENIOR VP/CFO
Credential:
Phone: 757-668-8565