Healthcare Provider Details

I. General information

NPI: 1962485540
Provider Name (Legal Business Name): AMERIGROUP CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 CORPORATION LN
VIRGINIA BEACH VA
23462-3103
US

IV. Provider business mailing address

4425 CORPORATION LN
VIRGINIA BEACH VA
23462-3103
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-6452
  • Fax: 757-222-2377
Mailing address:
  • Phone: 757-962-6452
  • Fax: 757-222-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. JMAES GORDEN CARLSON
Title or Position: PRESIDENT
Credential:
Phone: 757-962-6452