Provider Demographics
NPI:1326082637
Name:COLUMBIA MEDICAL GROUP-SOUTHWEST VIRGINIA, IN
Entity Type:Organization
Organization Name:COLUMBIA MEDICAL GROUP-SOUTHWEST VIRGINIA, IN
Other - Org Name:PULASKI PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:2400 LEE HWY N
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-2326
Mailing Address - Country:US
Mailing Address - Phone:540-994-9443
Mailing Address - Fax:540-994-9330
Practice Address - Street 1:2400 LEE HWY N
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-2326
Practice Address - Country:US
Practice Address - Phone:540-994-9443
Practice Address - Fax:540-994-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326082637Medicaid
CD7688Medicare PIN
VAC06997Medicare PIN