Healthcare Provider Details

I. General information

NPI: 1265715932
Provider Name (Legal Business Name): MARY IMMACULATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SENTARA CIR SUITE 102
WILLIAMSBURG VA
23188-5727
US

IV. Provider business mailing address

500 SENTARA CIR SUITE 102
WILLIAMSBURG VA
23188-5727
US

V. Phone/Fax

Practice location:
  • Phone: 757-984-9890
  • Fax: 757-345-6659
Mailing address:
  • Phone: 757-984-9890
  • Fax: 757-345-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL K KERNER
Title or Position: CEO
Credential:
Phone: 757-673-5929