Provider Demographics
NPI:1922182112
Name:GRAYSON HIGHLANDS FAMILY MEDICINE & OBSTETRICS
Entity Type:Organization
Organization Name:GRAYSON HIGHLANDS FAMILY MEDICINE & OBSTETRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LINEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-773-2865
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-0947
Mailing Address - Country:US
Mailing Address - Phone:276-773-2865
Mailing Address - Fax:276-773-0843
Practice Address - Street 1:127 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348
Practice Address - Country:US
Practice Address - Phone:276-773-2865
Practice Address - Fax:276-773-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005610681Medicaid
VA080007351Medicare ID - Type Unspecified
P07871Medicare UPIN
VAC06367Medicare ID - Type UnspecifiedGROUP #
VA500000612Medicare ID - Type Unspecified
G82117Medicare UPIN