Provider Demographics
NPI:1700434420
Name:CENTRAL VIRGINIA GYNECOLOGIC ONCOLOGY PC
Entity Type:Organization
Organization Name:CENTRAL VIRGINIA GYNECOLOGIC ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SEGURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-323-5040
Mailing Address - Street 1:1401 JOHNSTON WILLIS DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4730
Mailing Address - Country:US
Mailing Address - Phone:804-323-5040
Mailing Address - Fax:804-323-5070
Practice Address - Street 1:9101 STONY POINT DR # 3300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1979
Practice Address - Country:US
Practice Address - Phone:804-323-5040
Practice Address - Fax:804-272-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006215149Medicaid