Provider Demographics
NPI:1144332727
Name:WILEY J LATHAM MD AND BERNICE G LATHAM MD PARTNERS
Entity type:Organization
Organization Name:WILEY J LATHAM MD AND BERNICE G LATHAM MD PARTNERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILEY
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:804-780-3008
Mailing Address - Street 1:PO BOX 15483
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-0000
Mailing Address - Country:US
Mailing Address - Phone:804-780-3008
Mailing Address - Fax:804-780-3014
Practice Address - Street 1:505 WEST LEIGH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-780-3008
Practice Address - Fax:804-780-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023313207RG0100X
VA0101023261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5671051Medicaid
VA6071066Medicaid
VA5671051Medicaid
B388Medicare PIN
VA6071066Medicaid