Healthcare Provider Details

I. General information

NPI: 1871639658
Provider Name (Legal Business Name): BRANDERMILL PEDIATRIC & ADOLESCENT MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4902 MILLRIDGE PKWY E
MIDLOTHIAN VA
23112-4828
US

IV. Provider business mailing address

4902 MILLRIDGE PKWY E
MIDLOTHIAN VA
23112-4828
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-1231
  • Fax: 804-744-9521
Mailing address:
  • Phone: 804-744-1231
  • Fax: 804-744-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number0101030363
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. JUDITH F MCGHEE
Title or Position: OWNER
Credential: MD
Phone: 804-744-1231