Provider Demographics
NPI:1982688818
Name:VIRGINIA BREAST CENTER INC
Entity Type:Organization
Organization Name:VIRGINIA BREAST CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:PELLICANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:804-594-3130
Mailing Address - Street 1:13700 SAINT FRANCIS BLVD
Mailing Address - Street 2:STE 510
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-3267
Mailing Address - Country:US
Mailing Address - Phone:804-594-3130
Mailing Address - Fax:804-594-3130
Practice Address - Street 1:13700 SAINT FRANCIS BLVD
Practice Address - Street 2:STE 510
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3267
Practice Address - Country:US
Practice Address - Phone:804-594-3130
Practice Address - Fax:804-594-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045452208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10187419Medicaid
VAG77631Medicare UPIN
VAF83316Medicare UPIN