Provider Demographics
NPI:1760223390
Name:804 MED LLC
Entity type:Organization
Organization Name:804 MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-517-6853
Mailing Address - Street 1:425 N ARTHUR ASHE BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3306
Mailing Address - Country:US
Mailing Address - Phone:804-517-6853
Mailing Address - Fax:
Practice Address - Street 1:515 RAY C HUNT DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2981
Practice Address - Country:US
Practice Address - Phone:434-244-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty