Provider Demographics
NPI:1881792661
Name:ADVANCED FAMILY PRACTICE
Entity type:Organization
Organization Name:ADVANCED FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-347-4357
Mailing Address - Street 1:11453 ABBOTS CROSS LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-1102
Mailing Address - Country:US
Mailing Address - Phone:804-347-4357
Mailing Address - Fax:
Practice Address - Street 1:11453 ABBOTS CROSS LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-1102
Practice Address - Country:US
Practice Address - Phone:804-347-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005647134Medicaid
VA00V481A54Medicare ID - Type Unspecified
VA005647134Medicaid