Provider Demographics
NPI:1255431250
Name:SOUTHWEST VIRGINIA ORTHOPEDIC AND SPINE LLC
Entity type:Organization
Organization Name:SOUTHWEST VIRGINIA ORTHOPEDIC AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-237-7760
Mailing Address - Street 1:809 DAVIS ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7013
Mailing Address - Country:US
Mailing Address - Phone:540-951-6000
Mailing Address - Fax:540-951-9400
Practice Address - Street 1:809 DAVIS ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7013
Practice Address - Country:US
Practice Address - Phone:540-951-6000
Practice Address - Fax:540-951-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255431250Medicaid
VADG1185OtherRR MEDICARE
VA1255431250Medicaid
VA6409020001Medicare NSC
VAC10068Medicare PIN