Healthcare Provider Details

I. General information

NPI: 1568160075
Provider Name (Legal Business Name): MICHAEL M WITHIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6163 E VIRGINIA BEACH BLVD STE 9
NORFOLK VA
23502-2701
US

IV. Provider business mailing address

6163 E VIRGINIA BEACH BLVD STE 9
NORFOLK VA
23502-2701
US

V. Phone/Fax

Practice location:
  • Phone: 757-742-9933
  • Fax: 888-809-1957
Mailing address:
  • Phone: 757-742-9933
  • Fax: 888-809-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: