Provider Demographics
NPI:1912434663
Name:CENTRA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CENTRA MEDICAL GROUP, LLC
Other - Org Name:CMG LOCUMS
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-5047
Mailing Address - Street 1:2010 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1106
Practice Address - Country:US
Practice Address - Phone:434-947-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty