Healthcare Provider Details

I. General information

NPI: 1033556667
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 CHURCH ST
LYNCHBURG VA
24504-4603
US

IV. Provider business mailing address

2010 ATHERHOLT RD
LYNCHBURG VA
24501-1106
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEWIS ADDISON
Title or Position: SR VP CFO
Credential:
Phone: 434-200-4708