Provider Demographics
NPI:1568441897
Name:DERMATOLOGIC SURGERY OF CENTRAL VIRGINIA PLC
Entity Type:Organization
Organization Name:DERMATOLOGIC SURGERY OF CENTRAL VIRGINIA PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-979-7700
Mailing Address - Street 1:PO BOX 826696
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-6696
Mailing Address - Country:US
Mailing Address - Phone:434-979-7700
Mailing Address - Fax:434-979-7715
Practice Address - Street 1:902 E JEFFERSON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5397
Practice Address - Country:US
Practice Address - Phone:434-979-7700
Practice Address - Fax:434-979-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1092Medicare PIN
VAGO5678Medicare PIN