MEDICARE: CRIPPLED CHILDREN'S HOSPITAL

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	225X00000X	Occupational Therapist	H1842	VA

General Provider Information

NPI Number	:	1578600912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRIPPLED CHILDREN'S HOSPITAL

Provider Business Mailing Address
First Line	:	2924 BROOK RD
Second Line	:	CREDENTIALING DEPT
City	:	RICHMOND
State	:	VA
Zip	:	23220-1215
Country	:	US
Telephone Number	:	804-321-7474
Fax Number	:	804-321-2728

Provider Business Practice Location Address
First Line	:	2925 POLO PKWY
Second Line	:	CHILDREN'S HSOPITAL THERAPY CENTER
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-1453
Country	:	US
Telephone Number	:	804-323-9060
Fax Number	:	804-323-7576

Authorized Official
Title or Position	:	VICE PRESIDENT & CFO
Name	:	MR. SAMUEL G WEIDMAN
Credential	:
Telephone Number	:	804-321-7474

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/22/2020

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Practice Location Address:

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1326137985 — MRS. MADELINE M. BRYAN CCC/SLP
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1376632653 — JENNIFER LYN HAWLEY DPT
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1497835532 — MRS. GAIL DIVIZIO GRUBB M.A./CCC-SLP
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1154468981 — CRIPPLED CHILDREN'S HOSPITAL
Practice Location Address:

2925 POLO PKWY , CHILDREN'S HOSPITAL THERAPY CENTER
MIDLOTHIAN, VA
23113-1453

Practice Phone: 804-323-9060
Practice Fax: 804-323-7576

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