Provider Demographics
NPI:1336638865
Name:CENTRA MEDICAL GROUP. LLC
Entity Type:Organization
Organization Name:CENTRA MEDICAL GROUP. LLC
Other - Org Name:CMG SOUTHSIDE PULMONOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAYER CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-5047
Mailing Address - Street 1:1937 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1199
Practice Address - Country:US
Practice Address - Phone:434-315-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRA MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty