Provider Demographics
NPI:1700371358
Name:MGELLAN COMPLETE CARE VIRGINIA
Entity Type:Organization
Organization Name:MGELLAN COMPLETE CARE VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-762-6106
Mailing Address - Street 1:3829 GASKINS RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1437
Mailing Address - Country:US
Mailing Address - Phone:804-762-6106
Mailing Address - Fax:
Practice Address - Street 1:3829 GASKINS RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1437
Practice Address - Country:US
Practice Address - Phone:804-762-6106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGELLAN HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization