Provider Demographics
NPI:1528167483
Name:SENTARA PRINCESS ANNE HOSPITAL
Entity type:Organization
Organization Name:SENTARA PRINCESS ANNE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-455-7020
Mailing Address - Street 1:2025 GLENN MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0178
Mailing Address - Country:US
Mailing Address - Phone:757-507-1115
Mailing Address - Fax:757-507-0241
Practice Address - Street 1:2025 GLENN MITCHELL DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0178
Practice Address - Country:US
Practice Address - Phone:757-507-1115
Practice Address - Fax:757-716-3935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENTARA HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
VA02010041013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2105983OtherPK
VA4900570Medicaid