Provider Demographics
NPI:1417981648
Name:MEDIC 1
Entity Type:Organization
Organization Name:MEDIC 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:HEGADORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-371-1664
Mailing Address - Street 1:3429 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408
Mailing Address - Country:US
Mailing Address - Phone:540-371-1664
Mailing Address - Fax:540-371-2411
Practice Address - Street 1:3429 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408
Practice Address - Country:US
Practice Address - Phone:540-371-1664
Practice Address - Fax:540-371-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001678363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q10149Medicare UPIN
010124M96Medicare ID - Type Unspecified