Provider Demographics
NPI:1285721035
Name:RETREAT SURGICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:RETREAT SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:101 CORWARDIN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224
Mailing Address - Country:US
Mailing Address - Phone:804-230-4116
Mailing Address - Fax:804-230-4355
Practice Address - Street 1:101 CORWARDIN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224
Practice Address - Country:US
Practice Address - Phone:804-230-4116
Practice Address - Fax:804-230-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1285721035Medicaid
VA1285721035Medicaid