=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639709769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHWAY HEALTHCARE-VIRGINIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2020
-----------------------------------------------------
Last Update Date | 06/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1941 NEELEY RD
-----------------------------------------------------
City | BIG STONE GAP
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24219-4474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-544-7861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 URBAN CENTER DR STE 600
-----------------------------------------------------
City | VESTAVIA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-208-9312
-----------------------------------------------------
Fax | 205-848-2227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | MELISSA COX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-208-9312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------