Provider Demographics
NPI:1386921534
Name:PHYSICIAN ASSOCIATES OF CENTRAL VIRGINIA, LLC
Entity type:Organization
Organization Name:PHYSICIAN ASSOCIATES OF CENTRAL VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:434-947-3944
Mailing Address - Street 1:2215 LANDOVER PL
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2115
Mailing Address - Country:US
Mailing Address - Phone:434-947-3944
Mailing Address - Fax:866-617-8273
Practice Address - Street 1:2215 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2115
Practice Address - Country:US
Practice Address - Phone:434-947-3944
Practice Address - Fax:866-617-8273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL ASSOCIATES OF CENTRAL VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043535207T00000X
VA01010368192080P0006X
VA0101240226207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1386921534OtherTRICARE
VA1386921534Medicaid
1386921534OtherTRICARE