Provider Demographics
NPI:1790739761
Name:CHASE CITY PRIMARY CARE CENTER, LLC
Entity Type:Organization
Organization Name:CHASE CITY PRIMARY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-774-2400
Mailing Address - Street 1:200 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-1456
Mailing Address - Country:US
Mailing Address - Phone:434-372-0900
Mailing Address - Fax:434-372-8681
Practice Address - Street 1:200 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-1456
Practice Address - Country:US
Practice Address - Phone:434-372-0900
Practice Address - Fax:434-372-8681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5903162OtherNC MEDICAID #
VAC08915Medicare ID - Type UnspecifiedMEDICARE GROUP #
VAC08915Medicare PIN