MEDICARE: MIDLOTHIAN PRIMARY CARE, LTD.

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	207Q00000X	Family Medicine Physician	0101038159	VA

General Provider Information

NPI Number	:	1811942931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLOTHIAN PRIMARY CARE, LTD.

Provider Business Mailing Address
First Line	:	5001 W VILLAGE GREEN DR
Second Line	:	SUITE 205
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4801
Country	:	US
Telephone Number	:	804-744-6700
Fax Number	:	804-744-2047

Provider Business Practice Location Address
First Line	:	5001 W VILLAGE GREEN DR
Second Line	:	SUITE 205
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4801
Country	:	US
Telephone Number	:	804-744-6700
Fax Number	:	804-744-2047

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN ACHILLE KELLER
Credential	:	M.D.
Telephone Number	:	804-744-6700

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	10/31/2008

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