Provider Demographics
NPI:1093047797
Name:EASTERN STATE HOSPITAL
Entity Type:Organization
Organization Name:EASTERN STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAVRET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-253-5241
Mailing Address - Street 1:4601 IRONBOUND RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2648
Mailing Address - Country:US
Mailing Address - Phone:757-253-4309
Mailing Address - Fax:757-253-4625
Practice Address - Street 1:4601 IRONBOUND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2648
Practice Address - Country:US
Practice Address - Phone:757-253-4309
Practice Address - Fax:757-253-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049272283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital