Provider Demographics
NPI:1942393822
Name:FORK UNION MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:FORK UNION MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:EWING
Authorized Official - Last Name:LANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-842-3244
Mailing Address - Street 1:4064 JAMES MADISON HIGHWAY
Mailing Address - Street 2:PO BOX 458
Mailing Address - City:FORK UNION
Mailing Address - State:VA
Mailing Address - Zip Code:23055
Mailing Address - Country:US
Mailing Address - Phone:434-842-3244
Mailing Address - Fax:434-842-1110
Practice Address - Street 1:4064 JAMES MADISON HIGHWAY
Practice Address - Street 2:
Practice Address - City:FORK UNION
Practice Address - State:VA
Practice Address - Zip Code:23055
Practice Address - Country:US
Practice Address - Phone:434-842-3244
Practice Address - Fax:434-842-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B06283Medicare UPIN
010001451Medicare ID - Type Unspecified