Healthcare Provider Details

I. General information

NPI: 1609110774
Provider Name (Legal Business Name): MID-ATLANTIC WOMENS CARE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 HEALTHY WAY SUITE 330
VIRGINIA BEACH VA
23462-7958
US

IV. Provider business mailing address

828 HEALTHY WAY SUITE 330
VIRGINIA BEACH VA
23462-7958
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-3890
  • Fax: 757-467-0301
Mailing address:
  • Phone: 757-461-3890
  • Fax: 757-467-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1701004447
License Number StateVA

VIII. Authorized Official

Name: REX G WATERBURY
Title or Position: PHYSICIAN
Credential: MD
Phone: 757-461-3890