Provider Demographics
NPI:1053322495
Name:PATRICK COUNTY FAMILY PRACTICE,PC
Entity Type:Organization
Organization Name:PATRICK COUNTY FAMILY PRACTICE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CLAUDE
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-694-4466
Mailing Address - Street 1:PO BOX 1019
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-1019
Mailing Address - Country:US
Mailing Address - Phone:276-694-4466
Mailing Address - Fax:276-694-2909
Practice Address - Street 1:18877 JEB STUART HIGHWAY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-1019
Practice Address - Country:US
Practice Address - Phone:276-694-4466
Practice Address - Fax:276-694-2909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATRICK COUNTY FAMILY PRACTICE,PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101 036915207Q00000X
VA0101 237621207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0232EOtherBLUE CROSS BLUE SHIELD
VA006211313Medicaid
VA097029OtherANTHEM BCBS GROUP #
NC7902459Medicaid
VA010181861Medicaid
VA005657342Medicaid
VA005657342Medicaid