Provider Demographics
NPI:1407006018
Name:GENERAL THORACIC SURGERY PC
Entity Type:Organization
Organization Name:GENERAL THORACIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUSOLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:ODUNTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-596-6715
Mailing Address - Street 1:3150 CLINCH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-2159
Mailing Address - Country:US
Mailing Address - Phone:276-596-6715
Mailing Address - Fax:276-596-6717
Practice Address - Street 1:3150 CLINCH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2159
Practice Address - Country:US
Practice Address - Phone:276-596-6715
Practice Address - Fax:276-596-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240724208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174592125OtherINDIVIDUAL NPI