Healthcare Provider Details

I. General information

NPI: 1194267229
Provider Name (Legal Business Name): MARY IMMACULATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 MCMANUS BLVD SUITE 301
NEWPORT NEWS VA
23602-4414
US

IV. Provider business mailing address

7007 HARBOUR VIEW BLVD SUITE 108
SUFFOLK VA
23435-3657
US

V. Phone/Fax

Practice location:
  • Phone: 757-947-3838
  • Fax: 757-327-4280
Mailing address:
  • Phone: 757-215-2784
  • Fax: 757-215-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN SMITH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 757-215-2784