Provider Demographics
NPI:1124565585
Name:ORTHOVIRGINIA, INC
Entity Type:Organization
Organization Name:ORTHOVIRGINIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-533-2357
Mailing Address - Street 1:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-4067
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:13801 ST FRANCIS BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3206
Practice Address - Country:US
Practice Address - Phone:804-270-1305
Practice Address - Fax:804-273-9294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207X00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty