Healthcare Provider Details

I. General information

NPI: 1154634517
Provider Name (Legal Business Name): LYNCHBURG FAMILY MEDICINE RESIDENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 MEMORIAL AVE 10
LYNCHBURG VA
24501-2661
US

IV. Provider business mailing address

2323 MEMORIAL AVE
LYNCHBURG VA
24501-2661
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-5200
  • Fax:
Mailing address:
  • Phone: 434-200-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number116022195
License Number StateVA

VIII. Authorized Official

Name: DR. CHARLES E. DRISCOLL
Title or Position: DIRECTOR
Credential: M.D.
Phone: 434-200-5200