Provider Demographics
NPI:1770572885
Name:CJW SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:CJW SPORTS MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:5309 COMMONWEALTH PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23112
Mailing Address - Country:US
Mailing Address - Phone:804-745-9000
Mailing Address - Fax:804-330-7055
Practice Address - Street 1:5309 COMMONWEALTH PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23112
Practice Address - Country:US
Practice Address - Phone:804-745-9000
Practice Address - Fax:804-330-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1770572885Medicaid
VA1770572885Medicaid