Healthcare Provider Details

I. General information

NPI: 1962429498
Provider Name (Legal Business Name): OBICI MEDICAL MANAGEMENT SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 HOLLAND RD # B
SUFFOLK VA
23434-6528
US

IV. Provider business mailing address

1548 HOLLAND RD # B
SUFFOLK VA
23434-6528
US

V. Phone/Fax

Practice location:
  • Phone: 757-925-0706
  • Fax: 757-539-4750
Mailing address:
  • Phone: 757-925-0706
  • Fax: 757-539-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101018926
License Number StateVA

VIII. Authorized Official

Name: WILLIAM A CARPENTER
Title or Position: SRVP-CFO
Credential:
Phone: 757-934-4000