Provider Demographics
NPI:1962443721
Name:FORT CHISWELL FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:FORT CHISWELL FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-650-2907
Mailing Address - Street 1:245 FORT CHISWELL RD
Mailing Address - Street 2:FORT CHISWELL PLAZA SUITE D
Mailing Address - City:MAX MEADOWS
Mailing Address - State:VA
Mailing Address - Zip Code:24360-3986
Mailing Address - Country:US
Mailing Address - Phone:276-637-4300
Mailing Address - Fax:276-637-4301
Practice Address - Street 1:245 FORT CHISWELL RD
Practice Address - Street 2:FORT CHISWELL PLAZA SUITE D
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360-3986
Practice Address - Country:US
Practice Address - Phone:276-637-4300
Practice Address - Fax:276-637-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962443721Medicaid
VAC09694Medicare PIN