Provider Demographics
NPI:1356564066
Name:CRIPPLED CHILDREN'S HOSPITAL
Entity type:Organization
Organization Name:CRIPPLED CHILDREN'S HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WEIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-321-7474
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-321-2728
Practice Address - Street 1:206 TWINRIDGE LN STE A
Practice Address - Street 2:CHILDREN'S HOSPITAL BON AIR THERAPY CENTER
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-5244
Practice Address - Country:US
Practice Address - Phone:804-323-9060
Practice Address - Fax:804-323-7576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1842225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid