Organization
VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM
Active
Other names
VCU Sports Medicine-VCU Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DOMINIC J PULEO (CFO)
(804) 828-1295
Entity
Organization
Contact information
Practice address
1300 W BROAD ST, RICHMOND, VA 23284-9089
(804) 828-6315
Mailing address
PO BOX 758997, BALTIMORE, MD 21275-0001
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
H1875
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
180914
ANTHEM
VA
01
—
442277
ANTHEM-VCU SPORTS MEDICINE
VA
Enumeration date
04/23/2007
Last updated
12/31/2010
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