Provider Demographics
NPI:1811107097
Name:PIEDMONT FAMILY PRACTICE, PLC
Entity type:Organization
Organization Name:PIEDMONT FAMILY PRACTICE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VON ELTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-347-4400
Mailing Address - Street 1:493 BLACKWELL RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:493 BLACKWELL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2639
Practice Address - Country:US
Practice Address - Phone:540-341-1704
Practice Address - Fax:540-341-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028495174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10035490Medicaid
VA10035392Medicaid
VA10035503Medicaid
VA10035414Medicaid
VA10035414Medicaid
H47581Medicare UPIN
H54863Medicare UPIN
00V662P76Medicare ID - Type Unspecified
H00803Medicare UPIN
B60023Medicare UPIN
00776P76Medicare ID - Type Unspecified
VA10035490Medicaid
F07461Medicare UPIN
00V660P76Medicare ID - Type Unspecified
H68899Medicare UPIN
H53851Medicare UPIN
00V665P76Medicare ID - Type Unspecified
VA00V661P76Medicare ID - Type Unspecified
B07685Medicare UPIN
00V659P76Medicare ID - Type Unspecified