Provider Demographics
NPI:1376619254
Name:CENTRA HEALTH INC
Entity Type:Organization
Organization Name:CENTRA HEALTH INC
Other - Org Name:TATE SPRINGS MAMMOGRAPHY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-4708
Mailing Address - Street 1:1204 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1122
Practice Address - Country:US
Practice Address - Phone:434-947-7764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRA HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06754Medicare PIN
CA1601Medicare PIN
CA7804Medicare PIN