MEDICARE: EMERGENCY PHYSICIANS IMMEDIATE CARE CENTER 1 PLLC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1396330064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERGENCY PHYSICIANS IMMEDIATE CARE CENTER 1 PLLC

Provider Business Mailing Address
First Line	:	12214 W BROAD ST STE B
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1062
Country	:	US
Telephone Number	:	804-362-8345
Fax Number	:	855-224-1594

Provider Business Practice Location Address
First Line	:	12214 W BROAD ST STE B
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1062
Country	:	US
Telephone Number	:	804-362-8345
Fax Number	:	855-224-1594

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	TINA JEANNETTE LESTER
Credential	:
Telephone Number	:	804-437-0255

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	07/26/2021

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