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NPI Code Detail

MEDICARE: WELLNESSMD @ ACAC LLC

MEDICARE: WELLNESSMD @ ACAC 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
1207QS0010XSports Medicine (Family Medicine) PhysicianVA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
100X553W38OTHERINDIVIDUAL TPAN
2C10038OTHERGROUP PTAN

General Provider Information

NPI Number : 1396932323
Entity Type Code : Organization
Provider Name (Legal Business Name) : WELLNESSMD @ ACAC LLC
Provider Business Mailing Address
First Line : 406 ALBEMARLE SQUARE
Second Line :
City : CHARLOTTESVILLE
State : VA
Zip : 22901-1472
Country : US
Telephone Number : 434-817-4280
Fax Number : 434-817-4281
Provider Business Practice Location Address
First Line : 406 ALBEMARLE SQ
Second Line :
City : CHARLOTTESVILLE
State : VA
Zip : 22901-1472
Country : US
Telephone Number : 434-817-4280
Fax Number : 434-817-4281
Authorized Official
Title or Position : OWNER
Name : PHIL G WENDEL
Credential :
Telephone Number : 434-974-9890
Provider Enumeration Date : 10/03/2007
Last Update Date : 04/22/2008

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