Healthcare Provider Details

I. General information

NPI: 1730780461
Provider Name (Legal Business Name): HARTWELL THOMAS RAINEY V PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15769 WC MAIN ST
MIDLOTHIAN VA
23113-7327
US

IV. Provider business mailing address

15769 WC MAIN ST
MIDLOTHIAN VA
23113-7327
US

V. Phone/Fax

Practice location:
  • Phone: 804-419-9760
  • Fax:
Mailing address:
  • Phone: 804-794-5598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0110007757
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: