=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154381333
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDRICK NEWELL SOUTHERN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2006
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5589 GREENWICH RD STE 100
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-437-2882
-----------------------------------------------------
Fax | 757-502-8800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5589 GREENWICH RD STE 100
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-437-2882
-----------------------------------------------------
Fax | 757-502-8800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 0101044423
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------