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General NPI Number Information
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NPI Number | 1407006018
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Entity Type | Organization
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Legal Business Name | GENERAL THORACIC SURGERY PC
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Dates
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Enumeration Date | 09/19/2008
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Last Update Date | 09/19/2008
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Provider Practice Location Address
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Address Line | 3150 CLINCH ST SUITE 104
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City | RICHLANDS
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State | VA
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Zip | 24641-2159
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Country | US
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Telephone | 276-596-6715
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Fax | 276-596-6717
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Provider Business Mailing Address
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Address Line | 3150 CLINCH ST SUITE 104
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City | RICHLANDS
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State | VA
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Zip | 24641-2159
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Country | US
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Telephone | 276-596-6715
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Fax | 276-596-6717
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Authorized Official
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Title or Position | OWNER
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Name | OLUSOLA O ODUNTAN
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Credential | MD
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Telephone | 276-596-6715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 0101240724
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 0101240724
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License Number State | VA
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