Healthcare Provider Details

I. General information

NPI: 1558614958
Provider Name (Legal Business Name): VIRGINIA BEACH SURGERY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 FIRST COLONIAL RD
VIRGINIA BEACH VA
23454-3002
US

IV. Provider business mailing address

PO BOX 4159
VIRGINIA BEACH VA
23454-0159
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-2313
  • Fax:
Mailing address:
  • Phone: 757-481-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CANDACE MARTIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 757-481-2313