Provider Demographics
NPI:1033135314
Name:MED ATLANTIC INC
Entity Type:Organization
Organization Name:MED ATLANTIC INC
Other - Org Name:MED ATLANTIC INC DBA UROSURGICAL CTR OF RICHMOND
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIGETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-6100
Mailing Address - Street 1:9101 STONY POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-2002
Mailing Address - Country:US
Mailing Address - Phone:804-287-6100
Mailing Address - Fax:
Practice Address - Street 1:9101 STONY POINT PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-2002
Practice Address - Country:US
Practice Address - Phone:804-287-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH679261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007631405Medicaid
VA0597537OtherAETNA PPO
VA490000221OtherRAILROAD MEDICARE
VA0597537OtherAETNA PPO
VA0597537OtherAETNA PPO