Provider Demographics
NPI:1902095540
Name:WYNDHURST FAMILY MEDICINE, P.C.
Entity type:Organization
Organization Name:WYNDHURST FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESID
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-237-3664
Mailing Address - Street 1:102 ARCHWAY CT
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2889
Mailing Address - Country:US
Mailing Address - Phone:434-237-3664
Mailing Address - Fax:434-237-3711
Practice Address - Street 1:102 ARCHWAY CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2889
Practice Address - Country:US
Practice Address - Phone:434-237-3664
Practice Address - Fax:434-237-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146316OtherANTHEM
VA146316OtherANTHEM
VA005815W54Medicare PIN