Provider Demographics
NPI:1336367630
Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM
Entity Type:Organization
Organization Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM
Other - Org Name:VCU SPORTS MEDICINE-VCU SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:PULEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-828-1295
Mailing Address - Street 1:PO BOX 758997
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23284-9089
Practice Address - Country:US
Practice Address - Phone:804-828-6315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1875261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA180914OtherANTHEM
VA442277OtherANTHEM-VCU SPORTS MEDICINE