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General NPI Number Information
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NPI Number | 1760223390
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Entity Type | Organization
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Legal Business Name | 804 MED LLC
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Dates
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Enumeration Date | 06/06/2024
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Last Update Date | 06/06/2024
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Provider Practice Location Address
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Address Line | 515 RAY C HUNT DR
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-2981
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Country | US
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Telephone | 434-244-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 425 N ARTHUR ASHE BLVD APT 2
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City | RICHMOND
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State | VA
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Zip | 23220-3306
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Country | US
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Telephone | 804-517-6853
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MATTHEW H THOMPSON
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Credential | MD
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Telephone | 804-517-6853
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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