Provider Demographics
NPI:1053778845
Name:COLONIAL ORTHOPAEDICS INC
Entity type:Organization
Organization Name:COLONIAL ORTHOPAEDICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-571-5106
Mailing Address - Street 1:325 CHARLES H DIMMOCK PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2986
Mailing Address - Country:US
Mailing Address - Phone:804-526-5888
Mailing Address - Fax:804-526-5401
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:804-526-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036726207X00000X
207X00000X
VA0101257013207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053778845Medicaid
VAC01167Medicare PIN