=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124038849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENINSULA PULMONARY ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 03/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 J CLYDE MORRIS BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 J CLYDE MORRIS BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LORRAINE LINDSAY WATKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-594-3084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------