1346270329 NPI number — MARY IMMACULATE AMBULATORY SURGERY CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346270329 NPI number — MARY IMMACULATE AMBULATORY SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY IMMACULATE AMBULATORY SURGERY CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346270329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12720 MCMANUS BLVD
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23602-4441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-369-7000
Provider Business Mailing Address Fax Number:
757-369-3465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12720 MCMANUS BLVD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23602-4441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-369-7000
Provider Business Practice Location Address Fax Number:
757-369-3465
Provider Enumeration Date:
07/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORAN
Authorized Official First Name:
JENETHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3893

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  OH686 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010113181 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00165787 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".