Healthcare Provider Details

I. General information

NPI: 1063450070
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY OF VIRGINIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 FOREST AVE SUITE 401
RICHMOND VA
23229-4942
US

IV. Provider business mailing address

7603 FOREST AVE SUITE 401
RICHMOND VA
23229-4942
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-1611
  • Fax: 804-285-1615
Mailing address:
  • Phone: 804-285-1611
  • Fax: 804-285-1615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAGE KIDWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 804-285-1611