Provider Demographics
NPI:1043267693
Name:CHARLES CITY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CHARLES CITY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LERLA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-230-4913
Mailing Address - Street 1:921 HULL ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4069
Mailing Address - Country:US
Mailing Address - Phone:804-230-4913
Mailing Address - Fax:800-609-6810
Practice Address - Street 1:921 HULL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4069
Practice Address - Country:US
Practice Address - Phone:804-230-4913
Practice Address - Fax:804-233-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052550207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5620911Medicaid
VAC03122Medicare UPIN
VAC05718Medicare UPIN
C03122Medicare PIN