Healthcare Provider Details

I. General information

NPI: 1053515171
Provider Name (Legal Business Name): VIRGINIA BEACH ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 HEALTHY WAY #115
VIRGINIA BEACH VA
23462
US

IV. Provider business mailing address

PO BOX 778 VIRGINIA BEACH ANESTHESIA, LLC
MT. AIRY MD
21771
US

V. Phone/Fax

Practice location:
  • Phone: 757-495-8070
  • Fax: 757-282-5998
Mailing address:
  • Phone: 301-829-7683
  • Fax: 301-829-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101035576
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: REN J. LEWIS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 301-829-7683