Provider Demographics
NPI:1811942931
Name:MIDLOTHIAN PRIMARY CARE, LTD.
Entity type:Organization
Organization Name:MIDLOTHIAN PRIMARY CARE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ACHILLE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-744-6700
Mailing Address - Street 1:5001 W VILLAGE GREEN DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4801
Mailing Address - Country:US
Mailing Address - Phone:804-744-6700
Mailing Address - Fax:804-744-2047
Practice Address - Street 1:5001 W VILLAGE GREEN DR
Practice Address - Street 2:SUITE 205
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4801
Practice Address - Country:US
Practice Address - Phone:804-744-6700
Practice Address - Fax:804-744-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02554Medicare ID - Type UnspecifiedGROUP NUMBER
VAC36710Medicare UPIN