Healthcare Provider Details

I. General information

NPI: 1013198779
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 THOMSON DR
LYNCHBURG VA
24501-1009
US

IV. Provider business mailing address

2010 ATHERHOLT RD
LYNCHBURG VA
24501-1106
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-3933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LEWIS ADDISON
Title or Position: DIRECTOR
Credential:
Phone: 434-200-5047