Provider Demographics
NPI:1255604674
Name:PETER COLEMAN MD, LLC
Entity type:Organization
Organization Name:PETER COLEMAN MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-307-0818
Mailing Address - Street 1:204 N HAMILTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-2662
Mailing Address - Country:US
Mailing Address - Phone:804-307-0818
Mailing Address - Fax:
Practice Address - Street 1:204 N HAMILTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2662
Practice Address - Country:US
Practice Address - Phone:804-353-1230
Practice Address - Fax:804-353-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255604674Medicaid
VA1255604674Medicaid