Basic Information
| Provider Information | |||||||||
| NPI: | 1275791105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCV ASSOCIATED PHYSICIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCV PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91734 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232911734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043586100 | ||||||||
| FaxNumber: | 8043427619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E MARSHALL STREET | ||||||||
| Address2: | DERMATOLOGY | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232980510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048280300 | ||||||||
| FaxNumber: | 8048289596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2008 | ||||||||
| LastUpdateDate: | 05/28/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOUCHENS | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8048288707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCV ASSOCIATED PHYSICIANS | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPMSM CPCS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 5734371 | 05 | VA | MEDICAID |