Provider Demographics
NPI:1609818293
Name:CENTRA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CENTRA MEDICAL GROUP, LLC
Other - Org Name:AUTISM DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-5047
Mailing Address - Street 1:2010 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:693 LEESVILLE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2828
Practice Address - Country:US
Practice Address - Phone:434-200-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRA MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-11
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09704Medicare PIN