=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558747592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC CARDIOLOGY OF CENTRAL VIRGINIA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2015
-----------------------------------------------------
Last Update Date | 12/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7603 FOREST AVE SUITE 401
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-285-1611
-----------------------------------------------------
Fax | 804-285-1615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7603 FOREST AVE SUITE 401
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-285-1611
-----------------------------------------------------
Fax | 804-285-1615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARY FALTERMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-285-1611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------