Healthcare Provider Details

I. General information

NPI: 1184662769
Provider Name (Legal Business Name): VIRGINIA INTERVENTIONAL PAIN SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 FOREST AVE COURTYARD BUILDING, HENRICO DRS. HOSPITAL
RICHMOND VA
23229-4944
US

IV. Provider business mailing address

PO BOX 1269
MIDLOTHIAN VA
23113-8269
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-6160
  • Fax: 804-282-3120
Mailing address:
  • Phone: 804-282-6160
  • Fax: 804-282-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101040954
License Number StateVA

VIII. Authorized Official

Name: DANIEL C MARTIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 804-282-6160