Provider Demographics
NPI:1023000718
Name:BURKEVILLE MEDICAL GROUP
Entity Type:Organization
Organization Name:BURKEVILLE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-767-4822
Mailing Address - Street 1:412 NAMOZINE STREET
Mailing Address - Street 2:
Mailing Address - City:BURKEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23922
Mailing Address - Country:US
Mailing Address - Phone:434-767-5511
Mailing Address - Fax:
Practice Address - Street 1:412 NAMOZINE STREET
Practice Address - Street 2:
Practice Address - City:BURKEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23922
Practice Address - Country:US
Practice Address - Phone:434-767-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA493850Medicare Oscar/Certification