Healthcare Provider Details

I. General information

NPI: 1598184848
Provider Name (Legal Business Name): EASTERN VIRGINIA MEDICAL SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR RALEIGH BUILDING ROOM 304
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

207 MILLSPRING DR
FOREST VA
24551-2328
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3397
  • Fax:
Mailing address:
  • Phone: 434-525-7934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: LISA BRENNAN
Title or Position: RESIDENCY COORDINATOR
Credential:
Phone: 757-388-3397