Provider Demographics
NPI:1902091101
Name:VIRGINIAS DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:VIRGINIAS DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-326-3376
Mailing Address - Street 1:34 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2354
Mailing Address - Country:US
Mailing Address - Phone:276-326-3376
Mailing Address - Fax:276-326-3046
Practice Address - Street 1:1 COUNTRY CLUB HL
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4467
Practice Address - Country:US
Practice Address - Phone:276-326-3376
Practice Address - Fax:276-326-3046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9283461Medicare PIN