Provider Demographics
NPI:1780033050
Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY
Entity Type:Organization
Organization Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY
Other - Org Name:VCU HEALTH NEUROSCIENCE,ORTHOPAEDIC AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-828-0938
Mailing Address - Street 1:PO BOX 758997
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8997
Mailing Address - Country:US
Mailing Address - Phone:804-628-6643
Mailing Address - Fax:
Practice Address - Street 1:11958 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1007
Practice Address - Country:US
Practice Address - Phone:804-628-6643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1875282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00003OtherANTHEM