Provider Demographics
NPI:1790744423
Name:GLOUCESTER ORTHOPAEDIC CLINIC P C
Entity Type:Organization
Organization Name:GLOUCESTER ORTHOPAEDIC CLINIC P C
Other - Org Name:YORK RIVER ORTHOPAEDICS & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:BACH
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-693-4645
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-0646
Mailing Address - Country:US
Mailing Address - Phone:804-693-4645
Mailing Address - Fax:804-693-5985
Practice Address - Street 1:7584 HOSPITAL DR
Practice Address - Street 2:BUILDING C, SUITE 202
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4178
Practice Address - Country:US
Practice Address - Phone:804-693-4645
Practice Address - Fax:804-693-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042323207X00000X
VA0101032226207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB10211Medicare UPIN
VAB59946Medicare UPIN
VAC01293Medicare PIN
VA0410710001Medicare NSC