Healthcare Provider Details

I. General information

NPI: 1255545471
Provider Name (Legal Business Name): PIEDMONT PREFERRED WOMEN'S HEALTHCARE ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6890 GREENSBORO RD
RIDGEWAY VA
24148-3555
US

IV. Provider business mailing address

6890 GREENSBORO RD
RIDGEWAY VA
24148-3555
US

V. Phone/Fax

Practice location:
  • Phone: 276-956-1013
  • Fax:
Mailing address:
  • Phone: 276-956-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101241089
License Number StateVA

VIII. Authorized Official

Name: DR. MAKUNDA ABDUL-MBACKE
Title or Position: PRESIDENT
Credential: MD
Phone: 276-956-1013