Healthcare Provider Details

I. General information

NPI: 1235208711
Provider Name (Legal Business Name): BRUNSWICK FAMILY PRACTICE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 WEST CHURCH STREET
LAWRENCEVILLE VA
23868
US

IV. Provider business mailing address

POST OFFICE BOX 748 319 WEST CHURCH STREET
LAWRENCEVILLE VA
23868
US

V. Phone/Fax

Practice location:
  • Phone: 434-848-0072
  • Fax: 434-848-0141
Mailing address:
  • Phone: 434-848-0072
  • Fax: 434-848-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101038490
License Number StateVA

VIII. Authorized Official

Name: WILLIAM H HARRISON III
Title or Position: PRESIDENT
Credential: MD
Phone: 434-848-0072