Provider Demographics
NPI:1205185766
Name:ORTHOVIRGINIA, INC
Entity Type:Organization
Organization Name:ORTHOVIRGINIA, INC
Other - Org Name:COMMONWEALTH ORTHOPAEDICS & REHABILITATION, PC
Other - Org Type:Former Legal Business Name
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:19171-6230
Mailing Address - Country:US
Mailing Address - Phone:180-491-5191
Mailing Address - Fax:703-385-1062
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 303
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-810-5202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA538695Medicare PIN