Provider Demographics
NPI:1396826046
Name:DOMINION MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:DOMINION MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEND
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-225-7148
Mailing Address - Street 1:PO BOX 5449
Mailing Address - Street 2:304 EAST LEIGH STREET
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-0449
Mailing Address - Country:US
Mailing Address - Phone:804-225-7148
Mailing Address - Fax:804-225-7159
Practice Address - Street 1:304 E LEIGH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1410
Practice Address - Country:US
Practice Address - Phone:804-225-7148
Practice Address - Fax:804-225-7159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396826046OtherNPI GROUP NUMBER
VA=========OtherTAXES ID #
VA1396826046OtherNPI GROUP NUMBER
C02365Medicare PIN