MEDICARE: INTERNAL MEDICINE KIDNEY & HYPERTENSION CENTER PC

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	207RN0300X	Nephrology Physician	0101024987	VA
2	207R00000X	Internal Medicine Physician	0101024987	VA

General Provider Information

NPI Number	:	1497823728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNAL MEDICINE KIDNEY & HYPERTENSION CENTER PC

Provider Business Mailing Address
First Line	:	5700 LAKE WRIGHT DR STE 101
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-1859
Country	:	US
Telephone Number	:	757-502-4840
Fax Number	:	757-502-4841

Provider Business Practice Location Address
First Line	:	5700 LAKE WRIGHT DR STE 101
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-1859
Country	:	US
Telephone Number	:	757-502-4840
Fax Number	:	757-502-4841

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HUMBERTO F. PAVON
Credential	:	M.D.
Telephone Number	:	757-502-4840

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	06/18/2015

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