Provider Demographics
NPI:1770613044
Name:RETREAT CARDIOLOGY LLC
Entity type:Organization
Organization Name:RETREAT CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:505 W LEIGH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3239
Mailing Address - Country:US
Mailing Address - Phone:804-788-0004
Mailing Address - Fax:804-643-5935
Practice Address - Street 1:505 W LEIGH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-3239
Practice Address - Country:US
Practice Address - Phone:804-788-0004
Practice Address - Fax:804-643-5935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1770613044Medicaid
VA1770613044Medicaid