=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174109490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALABILITYMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2021
-----------------------------------------------------
Last Update Date | 03/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7214 SHENFIELD AVE
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23059-6614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-690-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7214 SHENFIELD AVE
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23059-6614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-690-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | PETER BUCKMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-690-9790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------