Healthcare Provider Details

I. General information

NPI: 1033497649
Provider Name (Legal Business Name): EXECUTIVE HEALTH GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2011
Last Update Date: 07/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD SUITE 550-A
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

7101 JAHNKE RD SUITE 550-A
RICHMOND VA
23225-4017
US

V. Phone/Fax

Practice location:
  • Phone: 804-560-3295
  • Fax: 804-560-9577
Mailing address:
  • Phone: 804-560-3295
  • Fax: 804-560-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057853
License Number StateVA

VIII. Authorized Official

Name: DR. JOHN RAND BAGGESEN
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 804-338-5157