Healthcare Provider Details

I. General information

NPI: 1124565585
Provider Name (Legal Business Name): ORTHOVIRGINIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13801 ST FRANCIS BOULEVARD SUITE 200
MIDLOTHIAN VA
23114-3206
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-4067
US

V. Phone/Fax

Practice location:
  • Phone: 804-270-1305
  • Fax: 804-273-9294
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE PROFFITT
Title or Position: CREDENTIALING & ENROLLMENT
Credential:
Phone: 804-533-2357