Healthcare Provider Details

I. General information

NPI: 1851366959
Provider Name (Legal Business Name): GLENN T RAUCHWARG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 DISCOVERY PARK BLVD SUITE 201
WILLIAMSBURG VA
23188
US

IV. Provider business mailing address

860 OMNI BLVD STE 101
NEWPORT NEWS VA
23606-4430
US

V. Phone/Fax

Practice location:
  • Phone: 757-345-2071
  • Fax: 757-903-4877
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102050179
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: