Healthcare Provider Details

I. General information

NPI: 1407006018
Provider Name (Legal Business Name): GENERAL THORACIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CLINCH ST SUITE 104
RICHLANDS VA
24641-2159
US

IV. Provider business mailing address

3150 CLINCH ST SUITE 104
RICHLANDS VA
24641-2159
US

V. Phone/Fax

Practice location:
  • Phone: 276-596-6715
  • Fax: 276-596-6717
Mailing address:
  • Phone: 276-596-6715
  • Fax: 276-596-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101240724
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101240724
License Number StateVA

VIII. Authorized Official

Name: OLUSOLA O ODUNTAN
Title or Position: OWNER
Credential: MD
Phone: 276-596-6715