Provider Demographics
NPI:1417978768
Name:GREATER VIRGINIA MEDICAL GROUP
Entity Type:Organization
Organization Name:GREATER VIRGINIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-282-9425
Mailing Address - Street 1:PO BOX 17085
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-7085
Mailing Address - Country:US
Mailing Address - Phone:804-282-9425
Mailing Address - Fax:804-282-6413
Practice Address - Street 1:2006 BREMO RD STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2438
Practice Address - Country:US
Practice Address - Phone:804-282-9425
Practice Address - Fax:804-282-6413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACL0385Medicare PIN
VAC03204Medicare PIN