Provider Demographics
NPI:1134338361
Name:SOUTHERN PHYSICAL MEDICINE ASSOCIATES INC
Entity type:Organization
Organization Name:SOUTHERN PHYSICAL MEDICINE ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:804-282-6593
Mailing Address - Street 1:5922 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2231
Mailing Address - Country:US
Mailing Address - Phone:804-282-6953
Mailing Address - Fax:804-282-8215
Practice Address - Street 1:5922 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2231
Practice Address - Country:US
Practice Address - Phone:804-282-6593
Practice Address - Fax:804-282-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0715002791101Y00000X
VA0101032689204C00000X, 204D00000X, 2081P0004X, 2081P2900X, 2081S0010X, 208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA066834400Medicaid
VA066834400Medicaid
C10561Medicare PIN