Provider Demographics
NPI:1720293467
Name:VCU HEALTH CHILDREN'S SERVICES AT BROOK ROAD
Entity Type:Organization
Organization Name:VCU HEALTH CHILDREN'S SERVICES AT BROOK ROAD
Other - Org Name:CRIPPLED CHILDREN'S HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-228-5202
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL
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 1:2924 BROOK RD
Practice Address - Street 2:CHILDREN'S HOSPITAL
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-321-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH18421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid