Healthcare Provider Details

I. General information

NPI: 1598770372
Provider Name (Legal Business Name): CARL RAPHAEL ST. REMY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 KEMPSVILLE RD BUILDING A
NORFOLK VA
23502-4700
US

IV. Provider business mailing address

PO BOX 741593 CHILDRENS SURGICAL SPECIALTY GROUP INC
ATLANTA GA
30374-1593
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-6550
  • Fax: 757-668-6544
Mailing address:
  • Phone: 757-668-8544
  • Fax: 757-668-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number0101235869
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: