Provider Demographics
NPI:1780079558
Name:MEDICAL AVENUE INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:MEDICAL AVENUE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / INCORPORATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ILIJA
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:RAKARIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-908-3095
Mailing Address - Street 1:1920 MEDICAL AVE
Mailing Address - Street 2:STE F
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-8016
Mailing Address - Country:US
Mailing Address - Phone:540-908-3095
Mailing Address - Fax:540-908-3085
Practice Address - Street 1:1920 MEDICAL AVE
Practice Address - Street 2:STE F
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8016
Practice Address - Country:US
Practice Address - Phone:540-908-3095
Practice Address - Fax:540-908-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054605261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184734154OtherNPI
21467OtherOPTIMA HEALTH
VA006023169Medicaid
211236OtherANTHEM
211236OtherANTHEM
1184734154OtherNPI