Provider Demographics
NPI:1194267229
Name:MARY IMMACULATE HOSPITAL
Entity type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-215-2784
Mailing Address - Street 1:7007 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3657
Mailing Address - Country:US
Mailing Address - Phone:757-215-2784
Mailing Address - Fax:757-215-2728
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-947-3838
Practice Address - Fax:757-327-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10716Medicare PIN