Provider Demographics
NPI:1114089075
Name:ATLANTIC OBSTETRICS & GYNOCOLOGY
Entity Type:Organization
Organization Name:ATLANTIC OBSTETRICS & GYNOCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-463-1234
Mailing Address - Street 1:3720 HOLLAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2859
Mailing Address - Country:US
Mailing Address - Phone:757-463-1234
Mailing Address - Fax:757-463-0453
Practice Address - Street 1:3720 HOLLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2859
Practice Address - Country:US
Practice Address - Phone:757-463-1234
Practice Address - Fax:757-463-0453
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC OBSTETRICS & GYNOCOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6242103Medicaid
VA6242103Medicaid
VAC04023Medicare PIN