Healthcare Provider Details

I. General information

NPI: 1326682980
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

IV. Provider business mailing address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-2072
  • Fax: 434-200-4252
Mailing address:
  • Phone: 434-200-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER NEAL
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 434-200-6905