Healthcare Provider Details

I. General information

NPI: 1144054792
Provider Name (Legal Business Name): ORTHOVIRGINIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 EAST WEST ROAD
MIDLOTHIAN VA
23114
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-2226
  • Fax: 804-282-5263
Mailing address:
  • Phone: 804-915-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

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