Healthcare Provider Details

I. General information

NPI: 1134338361
Provider Name (Legal Business Name): SOUTHERN PHYSICAL MEDICINE ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5922 W BROAD ST
RICHMOND VA
23230-2231
US

IV. Provider business mailing address

5922 W BROAD ST
RICHMOND VA
23230-2231
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-6593
  • Fax: 804-282-8215
Mailing address:
  • Phone: 804-282-6953
  • Fax: 804-282-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0715002791
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number0101032689
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number0101032689
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number0101032689
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101032689
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101032689
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0101032689
License Number StateVA
# 8
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101032689
License Number StateVA

VIII. Authorized Official

Name: DR. CHARLES H BONNER SR.
Title or Position: PRESIDENT
Credential:
Phone: 804-282-6593