Provider Demographics
NPI:1033149034
Name:MARYVIEW HOSPITAL LLC
Entity Type:Organization
Organization Name:MARYVIEW HOSPITAL LLC
Other - Org Name:DEEP CREEK FAMILY PRACTICE
Other - Org Type:Doing Business As
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 1:2605 MOSES GRANDY TRL
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-6712
Mailing Address - Country:US
Mailing Address - Phone:757-485-3600
Mailing Address - Fax:757-485-9458
Practice Address - Street 1:2605 MOSES GRANDY TRL
Practice Address - Street 2:SUITE D
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-6712
Practice Address - Country:US
Practice Address - Phone:757-485-3600
Practice Address - Fax:757-485-9458
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVIEW HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACC4075Medicare PIN
VAC05513Medicare PIN