=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942396908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WIGGINGTON ROAD FAMILY PRACTICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 06/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 WIGGINGTON ROAD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-385-7578
-----------------------------------------------------
Fax | 434-385-9756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 WIGGINGTON ROAD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-385-7578
-----------------------------------------------------
Fax | 434-385-9756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | ALAN M. PODOSEH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 434-385-7578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------