Provider Demographics
NPI:1184820185
Name:WEST AUGUSTA FAMILY PRACTICE
Entity Type:Organization
Organization Name:WEST AUGUSTA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELSEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-337-6002
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24421-0100
Mailing Address - Country:US
Mailing Address - Phone:540-337-6002
Mailing Address - Fax:540-337-6172
Practice Address - Street 1:21 SCENIC HIGHWAY
Practice Address - Street 2:101
Practice Address - City:CHURCHVILLE
Practice Address - State:VA
Practice Address - Zip Code:24421-0100
Practice Address - Country:US
Practice Address - Phone:540-337-6002
Practice Address - Fax:540-337-6172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048631174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005614759Medicaid
VA0801075800OtherRAILROAD MEDICARE
VA101527OtherANTHEM
VA21574OtherVIRGINIA PREMIER
VA277670OtherSOUTHERN HEALTH
VA=========24430A001OtherTRICARE
VA277670OtherSOUTHERN HEALTH
VA101527OtherANTHEM