Healthcare Provider Details

I. General information

NPI: 1457378895
Provider Name (Legal Business Name): ORTHOVIRGINIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 JOHNSTON WILLIS DR SUITE A
RICHMOND VA
23235-4765
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-379-8088
  • Fax: 804-794-6067
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-560-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE PROFFITT
Title or Position: CREDENTIALING & ENROLLMENT
Credential:
Phone: 804-533-2357