Healthcare Provider Details

I. General information

NPI: 1134226483
Provider Name (Legal Business Name): WILLOW BAY MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 JESSIE DUPONT MEMORIAL HWY
BURGESS VA
22432
US

IV. Provider business mailing address

PO BOX 219
BURGESS VA
22432-0219
US

V. Phone/Fax

Practice location:
  • Phone: 804-453-5466
  • Fax: 804-453-4728
Mailing address:
  • Phone: 804-453-5466
  • Fax: 804-453-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057095
License Number StateVA

VIII. Authorized Official

Name: DR. ANGELA ERNST
Title or Position: TREASURER AND SECRETARY
Credential: M.D.
Phone: 804-453-5466