Healthcare Provider Details

I. General information

NPI: 1417980343
Provider Name (Legal Business Name): WICKHAM TITUS HENDRIX AND TURNER PTRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 GROVE AVE
RICHMOND VA
23220-4438
US

IV. Provider business mailing address

2201 GROVE AVE
RICHMOND VA
23220-4438
US

V. Phone/Fax

Practice location:
  • Phone: 804-359-1351
  • Fax: 804-355-6625
Mailing address:
  • Phone: 804-359-1351
  • Fax: 804-355-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101049091
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101020690
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101047848
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101051667
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101056275
License Number StateVA

VIII. Authorized Official

Name: MS. TONYA LINN KEITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 804-359-1351