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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 493850 | Medicare Oscar/Certification |