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General NPI Number Information
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NPI Number | 1043055239
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Entity Type | Organization
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Legal Business Name | ORTHOVIRGINIA, INC
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Dates
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Enumeration Date | 06/28/2024
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Last Update Date | 06/28/2024
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Provider Practice Location Address
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Address Line | 2423 MAIN ST STE 3
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City | EVANSTON
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State | IL
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Zip | 60202-1547
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Country | US
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Telephone | 571-470-7544
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Fax |
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Provider Business Mailing Address
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Address Line | 2423 MAIN ST STE 3
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City | EVANSTON
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State | IL
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Zip | 60202-1547
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Country | US
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Telephone | 571-470-7544
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING AND ENROLLMENT
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Name | NICOLE PROFFITT
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Credential |
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Telephone | 804-533-2357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number |
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License Number State |
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