MEDICARE: FOREST HILL FAMILY PRACTICE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101021333	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CM6800	OTHER	VA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1124200779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREST HILL FAMILY PRACTICE, INC.

Provider Business Mailing Address
First Line	:	4405 FOREST HILL AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-3241
Country	:	US
Telephone Number	:	804-233-9661
Fax Number	:	804-233-1101

Provider Business Practice Location Address
First Line	:	4405 FOREST HILL AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-3241
Country	:	US
Telephone Number	:	804-233-9661
Fax Number	:	804-233-1101

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	JANICE ELLIS
Credential	:
Telephone Number	:	804-233-9661

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	03/13/2009

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