MEDICARE: FANYA N SEAGULL M.D.

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	208000000X	Pediatrics Physician	0101229010	VA

General Provider Information

NPI Number	:	1710999016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANYA N SEAGULL M.D.

Provider Business Mailing Address
First Line	:	2301 GENERAL BOOTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-7755
Country	:	US
Telephone Number	:	757-963-5500
Fax Number	:	757-275-9907

Provider Business Practice Location Address
First Line	:	2301 GENERAL BOOTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-7755
Country	:	US
Telephone Number	:	757-963-5500
Fax Number	:	757-275-9907

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	01/06/2012

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