Provider Demographics
NPI:1003130394
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:CARDIOVASCULAR SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-673-5928
Mailing Address - Street 1:12720 MCMANUS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4414
Mailing Address - Country:US
Mailing Address - Phone:757-875-5332
Mailing Address - Fax:757-874-1545
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-875-5332
Practice Address - Fax:757-874-1545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY IMMACULATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-16
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10716Medicare PIN