Provider Demographics
NPI:1972529261
Name:MED ATLANTIC INC DBA UROSURGICAL CTR OF RICHMOND
Entity type:Organization
Organization Name:MED ATLANTIC INC DBA UROSURGICAL CTR OF RICHMOND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-6100
Mailing Address - Street 1:9105 STONY POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1979
Mailing Address - Country:US
Mailing Address - Phone:804-287-6100
Mailing Address - Fax:
Practice Address - Street 1:5224 MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1405
Practice Address - Country:US
Practice Address - Phone:804-288-4137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED ATLANTIC INC DBA UROSURGICAL CTR OF RICHMOND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-14
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH677261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0597537OtherAETNA PPO
VA160657OtherSOUTHERN HEALTH
VA007631405Medicaid
VA490000221OtherRAILROAD MEDICARE
VA007631405Medicaid