Provider Demographics
NPI:1265437545
Name:COLLIVER, VIRGINIA C (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:C
Last Name:COLLIVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3100 WYMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6410 ROCKLEDGE DR
Practice Address - Street 2:STE 200
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1830
Practice Address - Country:US
Practice Address - Phone:301-897-5301
Practice Address - Fax:301-564-4289
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054597207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12470010OtherBCBS
MD991401300Medicaid
MD269931OtherMDIPA
MD122018OtherAETNA
MD493854OtherNCPPO
MD177656Medicare PIN
MD991401300Medicaid