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General NPI Number Information
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NPI Number | 1063467975
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Entity Type | Organization
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Legal Business Name | MEDIDOCTORS PRIMARY CARE LLC
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 10/17/2007
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Provider Practice Location Address
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Address Line | 1001 SAM PERRY BLVD
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-4453
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Country | US
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Telephone | 540-741-1428
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Fax | 540-741-1420
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Provider Business Mailing Address
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Address Line | 1001 SAM PERRY BLVD
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-4453
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Country | US
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Telephone | 540-741-1428
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Fax | 540-741-1420
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ROBERT K LIVELY
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Credential |
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Telephone | 540-741-1473
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RS0012X
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Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207VM0101X
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Taxonomy Name | Maternal & Fetal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number |
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License Number State |
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