Provider Demographics
NPI:1134450448
Name:TRI-CITY MULTI-SPECIALTY, LLC
Entity type:Organization
Organization Name:TRI-CITY MULTI-SPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:906 CROSSINGS BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-6503
Mailing Address - Country:US
Mailing Address - Phone:804-415-5000
Mailing Address - Fax:804-415-5015
Practice Address - Street 1:906 CROSSINGS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-6503
Practice Address - Country:US
Practice Address - Phone:804-415-5000
Practice Address - Fax:804-415-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134450448Medicaid
VAVAA101183Medicare PIN