=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023731676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SASA MITROVIC NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2022
-----------------------------------------------------
Last Update Date | 09/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E MARSHALL ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23298-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-628-7644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10813 PORTER PARK LN
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23059-8043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-484-0549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0001X
-----------------------------------------------------
Taxonomy Name | Advanced Heart Failure and Transplant Cardiology Physician
-----------------------------------------------------
License Number | 0024185229
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------