Provider Demographics
NPI:1427241090
Name:MEDIDOCTORS LLC
Entity type:Organization
Organization Name:MEDIDOCTORS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-741-1473
Mailing Address - Street 1:1101 SAM PERRY BLVD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4467
Mailing Address - Country:US
Mailing Address - Phone:540-741-2855
Mailing Address - Fax:540-741-2859
Practice Address - Street 1:1101 SAM PERRY BLVD
Practice Address - Street 2:SUITE 314
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4467
Practice Address - Country:US
Practice Address - Phone:540-741-2855
Practice Address - Fax:540-741-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06604Medicare PIN