Provider Demographics
NPI:1568489086
Name:MED ATLANTIC INC
Entity Type:Organization
Organization Name:MED ATLANTIC INC
Other - Org Name:MED ATLANTIC INC DBA UROSURGICAL CTR OF RICHMOND
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-6100
Mailing Address - Street 1:9105 STONY POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1979
Mailing Address - Country:US
Mailing Address - Phone:804-287-6100
Mailing Address - Fax:
Practice Address - Street 1:8228 MEADOWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2331
Practice Address - Country:US
Practice Address - Phone:804-730-5023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH679261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007631405Medicaid
VA160657OtherSOUTHERN HEALTH
VA0597537OtherAETNA PPO
VA007631405Medicaid
VA0597537OtherAETNA PPO