Healthcare Provider Details

I. General information

NPI: 1033120852
Provider Name (Legal Business Name): SEBASTIAN J KSIONSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 OAK LN
LYNCHBURG VA
24503
US

IV. Provider business mailing address

1330 OAK LN
LYNCHBURG VA
24503-2513
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-4175
  • Fax:
Mailing address:
  • Phone: 434-200-4175
  • Fax: 434-200-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11013088
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number55415
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101268046
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number54712
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number0101268046
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: