Provider Demographics
NPI:1164814612
Name:AFFINITY HEALTHCARE GROUP NEWTOWN LLC
Entity Type:Organization
Organization Name:AFFINITY HEALTHCARE GROUP NEWTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-962-0748
Mailing Address - Street 1:5715 PRINCESS ANNE RD
Mailing Address - Street 2:#106-107
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3222
Mailing Address - Country:US
Mailing Address - Phone:757-962-0748
Mailing Address - Fax:757-962-0876
Practice Address - Street 1:5715 PRINCESS ANNE RD
Practice Address - Street 2:#106-107
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3222
Practice Address - Country:US
Practice Address - Phone:757-962-0748
Practice Address - Fax:757-962-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201920207Q00000X
VA207QA0401X207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF092OtherMEDICARE PTAN