Provider Demographics
NPI:1760548259
Name:CHIPPENHAM PEDIATRIC SPECIALISTS LLC
Entity Type:Organization
Organization Name:CHIPPENHAM PEDIATRIC SPECIALISTS LLC
Other - Org Name:CJW PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-661-3365
Mailing Address - Street 1:101 COWARDIN AVE
Mailing Address - Street 2:STE. 207
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2078
Mailing Address - Country:US
Mailing Address - Phone:804-237-7761
Mailing Address - Fax:804-864-5216
Practice Address - Street 1:101 COWARDIN AVE
Practice Address - Street 2:STE. 207
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-2078
Practice Address - Country:US
Practice Address - Phone:804-237-7761
Practice Address - Fax:804-864-5216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1760548259Medicaid
VA1760548259Medicaid