MEDICARE: FORT NORFOLK PLAZA MEDICAL ASSOCIATES, LLC

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	261QP2300X	Primary Care Clinic/Center
2	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1366092231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT NORFOLK PLAZA MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	301 RIVERVIEW AVE STE 500
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23510-1066
Country	:	US
Telephone Number	:	757-624-1785
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 S MAIN ST STE A
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23523-1245
Country	:	US
Telephone Number	:	757-937-8929
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	PEGGY NEWBY
Credential	:
Telephone Number	:	757-624-1785

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	07/15/2020

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