Provider Demographics
NPI:1043055239
Name:ORTHOVIRGINIA, INC
Entity type:Organization
Organization Name:ORTHOVIRGINIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-533-2357
Mailing Address - Street 1:2423 MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1547
Mailing Address - Country:US
Mailing Address - Phone:571-470-7544
Mailing Address - Fax:
Practice Address - Street 1:2423 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1547
Practice Address - Country:US
Practice Address - Phone:571-470-7544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty