Provider Demographics
NPI:1205240231
Name:GYN CLINIC, LLC
Entity type:Organization
Organization Name:GYN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAKKRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACOG
Authorized Official - Phone:804-526-7229
Mailing Address - Street 1:648 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3632
Mailing Address - Country:US
Mailing Address - Phone:804-526-7229
Mailing Address - Fax:804-526-6007
Practice Address - Street 1:648 SOUTHPARK BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3632
Practice Address - Country:US
Practice Address - Phone:804-526-7229
Practice Address - Fax:804-526-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031880207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101031880OtherSTATE LICENSE NUMBER
VAB05971Medicare UPIN