Provider Demographics
NPI:1689600447
Name:COLONIAL ORTHOPAEDICS, INC
Entity Type:Organization
Organization Name:COLONIAL ORTHOPAEDICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-571-5106
Mailing Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2986
Mailing Address - Country:US
Mailing Address - Phone:804-526-5888
Mailing Address - Fax:804-526-5401
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:804-526-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036726207X00000X
VA0101226595207XS0106X
VA0101231604207XS0114X
VA0101237849207XS0117X
VA0101045456207XX0004X
VA0101052925207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010190096Medicaid
VA010190037Medicaid
VA010190606Medicaid
VA010193419Medicaid
VA010194911Medicaid
VA180887OtherANTHEM-DHILLON
VA180889OtherANTHEM-MARQUEEN
VA180890OtherANTHEM-PRAKASH
VA010195063Medicaid
VA180888OtherANTHEM-KALLURI
VA180891OtherANTHEM-SARAIYA
VA180892OtherANTHEM-SRIVASTAVA
VA010193419Medicaid
VA010195063Medicaid