Healthcare Provider Details

I. General information

NPI: 1326082637
Provider Name (Legal Business Name): COLUMBIA MEDICAL GROUP-SOUTHWEST VIRGINIA, IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LEE HWY N
PULASKI VA
24301-2326
US

IV. Provider business mailing address

2400 LEE HWY N
PULASKI VA
24301-2326
US

V. Phone/Fax

Practice location:
  • Phone: 540-994-9443
  • Fax: 540-994-9330
Mailing address:
  • Phone: 540-994-9443
  • Fax: 540-994-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM TEDRICK JOHNSON
Title or Position: VP
Credential:
Phone: 804-237-7760