MEDICARE: PATRICK HENRY HOSPITAL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	PL005216	VA
2	261QA0600X	Adult Day Care Clinic/Center	PL005216	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629184072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRICK HENRY HOSPITAL, INC.

Provider Business Mailing Address
First Line	:	608 DENBIGH BLVD
Second Line	:	SUITE 600
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23608-4410
Country	:	US
Telephone Number	:	757-875-2023
Fax Number	:	757-875-2016

Provider Business Practice Location Address
First Line	:	3435 JOHN TYLER HWY
Second Line	:	BUILDING 2, SUITE A
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-1457
Country	:	US
Telephone Number	:	757-565-5305
Fax Number	:	757-875-2070

Authorized Official
Title or Position	:	SENIOR VP, LTC
Name	:	MR. WALTER W AUSTIN
Credential	:
Telephone Number	:	757-875-7846

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	01/26/2021

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