Basic Information
| Provider Information | |||||||||
| NPI: | 1184964124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRA MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | CENTRA MEDICAL GROUP STROOBANTS CARDIOVASCULAR CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011106 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2410 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342005252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | ADDISON | ||||||||
| AuthorizedOfficialFirstName: | LEWIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 4342003656 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRA MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.