Provider Demographics
NPI:1174643878
Name:SPOTSYLVANIA EMERGI-CENTER INC
Entity type:Organization
Organization Name:SPOTSYLVANIA EMERGI-CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DESIDERIO
Authorized Official - Middle Name:LANDAS
Authorized Official - Last Name:HEBRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-786-7637
Mailing Address - Street 1:992 BRAGG RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6979
Mailing Address - Country:US
Mailing Address - Phone:540-786-7637
Mailing Address - Fax:540-786-0810
Practice Address - Street 1:992 BRAGG RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6979
Practice Address - Country:US
Practice Address - Phone:540-786-7637
Practice Address - Fax:540-786-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022289208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA060154OtherANTHEM BLUE CROSS PPO
VA060133OtherANTHEM BLUE CROSS GROUP
VAB10279Medicare UPIN