MEDICARE: FCC PETERSBURG

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1508282864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FCC PETERSBURG

Provider Business Mailing Address
First Line	:	PO BOX 90026
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23804-9000
Country	:	US
Telephone Number	:	804-504-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 RIVER RD
Second Line	:
City	:	NORTH PRINCE GEORGE
State	:	VA
Zip	:	23860-1659
Country	:	US
Telephone Number	:	804-504-7200
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	CORINNA VAN
Credential	:
Telephone Number	:	804-504-7200

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	03/11/2014

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Directions to “FCC PETERSBURG ” Practice Location

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