Provider Demographics
NPI:1811661523
Name:VIRTUE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:VIRTUE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:M ED
Authorized Official - Phone:806-382-5064
Mailing Address - Street 1:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-1500
Mailing Address - Country:US
Mailing Address - Phone:940-255-6552
Mailing Address - Fax:940-202-7058
Practice Address - Street 1:1306 13TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2454
Practice Address - Country:US
Practice Address - Phone:940-255-6552
Practice Address - Fax:940-202-7058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health