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General NPI Number Information
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NPI Number | 1982470100
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Entity Type | Organization
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Legal Business Name | 1212 MED PLLC
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Dates
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Enumeration Date | 11/29/2023
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 405 E LABURNUM AVE STE 3
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City | RICHMOND
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State | VA
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Zip | 23222-2134
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Country | US
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Telephone | 540-200-8821
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Fax | 540-779-7889
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Provider Business Mailing Address
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Address Line | 674 LEES GAP RD
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City | FINCASTLE
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State | VA
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Zip | 24090-3869
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Country | US
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Telephone | 540-682-3082
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. HENRY BURGESS
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Credential | MD
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Telephone | 540-682-3082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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