=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538179015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APPOMATTOX RIVER MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 05/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 W POYTHRESS ST
-----------------------------------------------------
City | HOPEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23860-2532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-458-8557
-----------------------------------------------------
Fax | 804-541-7113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 W POYTHRESS ST
-----------------------------------------------------
City | HOPEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23860-2532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-458-8557
-----------------------------------------------------
Fax | 804-541-7113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CARTER SPALDING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-458-8557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------