Provider Demographics
NPI:1235208711
Name:BRUNSWICK FAMILY PRACTICE LTD
Entity Type:Organization
Organization Name:BRUNSWICK FAMILY PRACTICE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:434-848-0072
Mailing Address - Street 1:POST OFFICE BOX 748
Mailing Address - Street 2:319 WEST CHURCH STREET
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868
Mailing Address - Country:US
Mailing Address - Phone:434-848-0072
Mailing Address - Fax:434-848-0141
Practice Address - Street 1:319 WEST CHURCH STREET
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868
Practice Address - Country:US
Practice Address - Phone:434-848-0072
Practice Address - Fax:434-848-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA092366OtherANTHEM BLUE CROSS BLUE SH
VA005630576Medicaid
VA080003661Medicare PIN
VA005630576Medicaid