=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750450391
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES L VAN DYKE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 02/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 TATE SPRINGS RD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24501-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-594-2622
-----------------------------------------------------
Fax | 804-594-0915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35602
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-594-2622
-----------------------------------------------------
Fax | 804-594-0915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 0101038693
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------