Provider Demographics
NPI:1760447627
Name:PEDIATRIC NEUROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC NEUROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-288-9898
Mailing Address - Street 1:5875 BREMO RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-288-9898
Mailing Address - Fax:804-673-6616
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE 310
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-288-9898
Practice Address - Fax:804-673-6616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036179174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6154174Medicaid
VA6154174Medicaid
VAB07917Medicare UPIN