Provider Demographics
NPI:1568612265
Name:MARY IMMACULATE HOSPITAL LLC
Entity type:Organization
Organization Name:MARY IMMACULATE HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-561-7672
Mailing Address - Street 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:2 BERNARDINE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4404
Practice Address - Country:US
Practice Address - Phone:757-947-3838
Practice Address - Fax:757-886-6757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY IMMACULATE HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-30
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty