Provider Demographics
NPI:1639344641
Name:VIRGINIA COMMONWEALTH UNIVERSITY
Entity Type:Organization
Organization Name:VIRGINIA COMMONWEALTH UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR, DEPT. OF GENERAL PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CERTOSIMO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-828-2977
Mailing Address - Street 1:520 N 12TH STREET
Mailing Address - Street 2:LYONS BLDG ROOM 414
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-2977
Mailing Address - Fax:804-828-3159
Practice Address - Street 1:520 N 12TH STREET
Practice Address - Street 2:LYONS BLDG ROOM 414
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-2977
Practice Address - Fax:804-828-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008264261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA153654OtherUNITED CONCORDIA
VA5894Medicaid
VA453709OtherANTHEM