Basic Information
| Provider Information | |||||||||
| NPI: | 1023764982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APPOMATTOX RIVER PRIMARY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748482 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303748482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 815 W POYTHRESS ST | ||||||||
| Address2: | |||||||||
| City: | HOPEWELL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238602532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044588557 | ||||||||
| FaxNumber: | 8045417113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | BERGAMO | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIVISION VP/AO | ||||||||
| AuthorizedOfficialTelephone: | 8042675950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.