Provider Demographics
NPI:1538122486
Name:TUCKER, HENRY ST GEORGE III (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:ST GEORGE
Last Name:TUCKER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7202 GLEN FOREST DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3781
Mailing Address - Country:US
Mailing Address - Phone:804-673-0134
Mailing Address - Fax:804-673-1796
Practice Address - Street 1:6605 W BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1714
Practice Address - Country:US
Practice Address - Phone:804-287-3000
Practice Address - Fax:804-285-2981
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101019972207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA830000322OtherRR MEDICARE
VA237398OtherANTHEM BCBS VA
VAC01120OtherMEDICARE PTAN
VA006051227Medicaid
VA237398OtherANTHEM BCBS VA
VAD72133Medicare UPIN