Healthcare Provider Details

I. General information

NPI: 1679596647
Provider Name (Legal Business Name): ORTHOVIRGINIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date: 02/11/2022
Reactivation Date: 04/01/2022

III. Provider practice location address

1850 TOWN CENTER PKWY SUITE 400
RESTON VA
20190-3219
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 703-810-5202
  • Fax:
Mailing address:
  • Phone: 804-915-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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