=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396932323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESSMD @ ACAC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 04/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 ALBEMARLE SQ
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-817-4280
-----------------------------------------------------
Fax | 434-817-4281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 ALBEMARLE SQUARE
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-817-4280
-----------------------------------------------------
Fax | 434-817-4281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PHIL G WENDEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-974-9890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------