=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073070298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER BRESLIN MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2019
-----------------------------------------------------
Last Update Date | 02/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5540 FALMOUTH ST STE 103
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23230-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-495-8661
-----------------------------------------------------
Fax | 804-486-9819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4902 EVELYN BYRD RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-495-8661
-----------------------------------------------------
Fax | 804-486-9819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | DR. PETER B BRESLIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-495-8661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------