=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376680710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRIPPLED CHILDREN'S HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10124 W BROAD ST STE K CHILDREN'S HOSPITAL THERAPY CENTER
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23060-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-273-6656
-----------------------------------------------------
Fax | 804-273-6612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2924 BROOK RD CREDENTIALING DEPT
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23220-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-321-7474
-----------------------------------------------------
Fax | 804-321-2728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT & CFO
-----------------------------------------------------
Name | MR. SAMUEL G WEIDMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-321-7474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | H1842
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------