Provider Demographics
NPI: | 1952627119 |
---|---|
Name: | RIDGELINE PHYSICIAN SERVICES, PLC |
Entity Type: | Organization |
Organization Name: | RIDGELINE PHYSICIAN SERVICES, PLC |
Other - Org Name: | WELLSPRING SPECIALTY CLINIC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SOLE OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KHALID |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ATHAR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 540-321-4281 |
Mailing Address - Street 1: | 302 E DAVIS ST |
Mailing Address - Street 2: | |
Mailing Address - City: | CULPEPER |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22701-2808 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 540-321-4281 |
Mailing Address - Fax: | 540-812-4902 |
Practice Address - Street 1: | 15237 CREATIVITY DR |
Practice Address - Street 2: | |
Practice Address - City: | CULPEPER |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22701-2504 |
Practice Address - Country: | US |
Practice Address - Phone: | 540-321-4281 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-04-13 |
Last Update Date: | 2018-06-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
No | 207QA0000X | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | Group - Multi-Specialty |
No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 207YX0007X | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | Group - Multi-Specialty |
No | 207YX0602X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |
No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
No | 261QP1100X | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 1952627119 | Medicaid |