MEDICARE: COLONIAL HEIGHTS PEDIATRICS

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	208000000X	Pediatrics Physician	010156547	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275954349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL HEIGHTS PEDIATRICS

Provider Business Mailing Address
First Line	:	16011 KAIROS RD
Second Line	:	SUITE 100
City	:	SOUTH CHESTERFIELD
State	:	VA
Zip	:	23834-5207
Country	:	US
Telephone Number	:	804-520-2600
Fax Number	:	804-520-5853

Provider Business Practice Location Address
First Line	:	16011 KAIROS RD
Second Line	:	SUITE 100
City	:	SOUTH CHESTERFIELD
State	:	VA
Zip	:	23834-5207
Country	:	US
Telephone Number	:	804-520-2600
Fax Number	:	804-520-5853

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. JAWED IQBAL
Credential	:	M.D
Telephone Number	:	804-536-1332

Provider Enumeration Date	:	12/17/2013
Last Update Date	:	12/17/2013

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