Provider Demographics
NPI:1922605971
Name:YOUR VIRTUAL CLINIC PA
Entity Type:Organization
Organization Name:YOUR VIRTUAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-286-9149
Mailing Address - Street 1:450 OLD PEACHTREE RD NW STE 101
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7289
Mailing Address - Country:US
Mailing Address - Phone:888-210-3339
Mailing Address - Fax:
Practice Address - Street 1:601 21ST ST STE 300
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0860
Practice Address - Country:US
Practice Address - Phone:888-210-3339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-02
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty