Healthcare Provider Details

I. General information

NPI: 1003865122
Provider Name (Legal Business Name): VALLEY PEDIATRIC GROUP, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 COMMUNITY DR
WAYNESBORO VA
22980-9505
US

IV. Provider business mailing address

108 COMMUNITY DR
WAYNESBORO VA
22980-9505
US

V. Phone/Fax

Practice location:
  • Phone: 540-949-0118
  • Fax: 540-932-2059
Mailing address:
  • Phone: 540-949-0118
  • Fax: 540-932-2059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA TAYLOR HUMPHRIES
Title or Position: ADMINISTRATOR
Credential: CMM, CPC
Phone: 540-949-5862