MEDICARE: ORTHOVIRGINIA, INC

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	207X00000X	Orthopaedic Surgery Physician
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1588687552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOVIRGINIA, INC

Provider Business Mailing Address
First Line	:	PO BOX 715868
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19171-5868
Country	:	US
Telephone Number	:	804-915-1910
Fax Number	:

Provider Business Practice Location Address
First Line	:	13350 FRANKLIN FARM ROAD
Second Line	:	SUITE 220
City	:	HERNDON
State	:	VA
Zip	:	20171-4095
Country	:	US
Telephone Number	:	703-810-5204
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING/ENROLLMENT
Name	:	NICOLE PROFFITT
Credential	:
Telephone Number	:	804-533-2357

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	06/03/2022

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