Healthcare Provider Details

I. General information

NPI: 1164814612
Provider Name (Legal Business Name): AFFINITY HEALTHCARE GROUP NEWTOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 PRINCESS ANNE RD #106-107
VIRGINIA BEACH VA
23462-3222
US

IV. Provider business mailing address

5715 PRINCESS ANNE RD #106-107
VIRGINIA BEACH VA
23462-3222
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-0748
  • Fax: 757-962-0876
Mailing address:
  • Phone: 757-962-0748
  • Fax: 757-962-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number207QA0401X
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102201920
License Number StateVA

VIII. Authorized Official

Name: MR. RONALD A MARTIN JR.
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 757-962-0748