Provider Demographics
NPI:1093772766
Name:ALTIUS FAMILY AND SPORTS MEDICINE, PLC
Entity Type:Organization
Organization Name:ALTIUS FAMILY AND SPORTS MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:MARCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-290-0593
Mailing Address - Street 1:2530 GASKINS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-1483
Mailing Address - Country:US
Mailing Address - Phone:804-290-0593
Mailing Address - Fax:804-290-0594
Practice Address - Street 1:2530 GASKINS RD
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-1483
Practice Address - Country:US
Practice Address - Phone:804-290-0593
Practice Address - Fax:804-290-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
437410OtherAETNA
=========OtherTAX ID
437410OtherAETNA
P00166136Medicare ID - Type UnspecifiedMEDICARE RAILROAD
=========OtherUNITED HEALTHCARE