MEDICARE: ELISHA ALEXANDER IDC US NAVY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1093741993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISHA ALEXANDER IDC US NAVY

Provider Business Mailing Address
First Line	:	1200 RENFREW ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8915
Country	:	US
Telephone Number	:	757-467-0561
Fax Number	:	757-443-5706

Provider Business Practice Location Address
First Line	:	1959 MORRIS ST
Second Line	:	SUITE 120 BLDG Z101
City	:	NORFOLK
State	:	VA
Zip	:	23511-3427
Country	:	US
Telephone Number	:	757-443-0002
Fax Number	:	757-443-5607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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