=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235271990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENINSULA NEUROSURGICAL ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2102 EXECUTIVE DR
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-838-1844
-----------------------------------------------------
Fax | 757-838-4419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2102 EXECUTIVE DR
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-838-1844
-----------------------------------------------------
Fax | 757-838-4419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD BERNARD MCADAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 757-838-1844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101025890
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------