Basic Information
| Provider Information | |||||||||
| NPI: | 1740845072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AXLINE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | VCUHS GMEA | ||||||||
| Address2: | PO BOX 980257 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232980257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
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| Practice Location | |||||||||
| Address1: | VCUHS DEPT OF MEDPEDS RESIDENCY, 980163 | ||||||||
| Address2: | 1250 E. MARSHALL STREET | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048286685 | ||||||||
| FaxNumber: | 8048270503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2019 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.