MEDICARE: GYN CLINIC, LLC

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	207V00000X	Obstetrics & Gynecology Physician	0101031880	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0101031880	OTHER	VA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1205240231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GYN CLINIC, LLC

Provider Business Mailing Address
First Line	:	648 SOUTHPARK BLVD
Second Line	:	SUITE C
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3632
Country	:	US
Telephone Number	:	804-526-7229
Fax Number	:	804-526-6007

Provider Business Practice Location Address
First Line	:	648 SOUTHPARK BLVD
Second Line	:	SUITE C
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3632
Country	:	US
Telephone Number	:	804-526-7229
Fax Number	:	804-526-6007

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHAKKRIS SIRI
Credential	:	M.D., F.A.C.O.G.
Telephone Number	:	804-526-7229

Provider Enumeration Date	:	06/18/2014
Last Update Date	:	06/18/2014

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Directions to “GYN CLINIC, LLC ” Practice Location

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