Healthcare Provider Details

I. General information

NPI: 1386921534
Provider Name (Legal Business Name): PHYSICIAN ASSOCIATES OF CENTRAL VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 LANDOVER PL
LYNCHBURG VA
24501-2115
US

IV. Provider business mailing address

2215 LANDOVER PL
LYNCHBURG VA
24501-2115
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-3944
  • Fax: 866-617-8273
Mailing address:
  • Phone: 434-947-3944
  • Fax: 866-617-8273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number0101036819
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number0101043535
License Number StateVA

VIII. Authorized Official

Name: NICHOLAS CLEARY III
Title or Position: ADMINISTRATOR
Credential:
Phone: 434-947-3944