Provider Demographics
NPI:1215117437
Name:HAMPTON ROADS INTERNAL MEDICINE
Entity type:Organization
Organization Name:HAMPTON ROADS INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:ROTHFUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-827-1920
Mailing Address - Street 1:2115 EXECUTIVE DRIVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2411
Mailing Address - Country:US
Mailing Address - Phone:757-827-1920
Mailing Address - Fax:757-827-7509
Practice Address - Street 1:2115 EXECUTIVE DR
Practice Address - Street 2:SUITE 2A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2499
Practice Address - Country:US
Practice Address - Phone:757-827-1920
Practice Address - Fax:757-827-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10327OtherMEDICARE PTAN