=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275963530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOLOGY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 01/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1045 MAIN ST SUITE 1
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-792-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1045 MAIN ST SUITE 1
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. JONATHAN NORTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-792-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NR1301X
-----------------------------------------------------
Taxonomy Name | Rural Acute Care Hospital
-----------------------------------------------------
License Number | 0110004395
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------