Healthcare Provider Details

I. General information

NPI: 1740416452
Provider Name (Legal Business Name): KATHRYN MARIE RACKSON M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST DEPT. OF IM/GERIATRIC MEDICINE
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-254-3500
  • Fax: 804-254-1616
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101257839
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: