| Name | Value |
|---|---|
| PROVIDER TYPE | Group |
| CLASSIFICATION | Single Specialty |
| DEFINITION | A business group of one or more individual practitioners, all of who practice with the same area of specialization. |
| STATUS | Active |
| VA CODE | V183412 |
| X12 CODE | 193400000X |
| SPECIALTY CODE | 70 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252651 |
| EFFECTIVE DATE/TIME |
|