=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376992636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYVIEW HOSPITAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2016
-----------------------------------------------------
Last Update Date | 04/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12720 MCMANUS BLVD STE 308
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23602-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-947-3840
-----------------------------------------------------
Fax | 757-397-8026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 639898
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-9898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SYSTEM DIRECTOR
-----------------------------------------------------
Name | KIMBERLY M RALSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-996-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------