Provider Demographics
NPI:1275085599
Name:MIDDLE PENINSULA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MIDDLE PENINSULA MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-384-7902
Mailing Address - Street 1:PO BOX 1498
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-1498
Mailing Address - Country:US
Mailing Address - Phone:804-725-0100
Mailing Address - Fax:804-725-3158
Practice Address - Street 1:9184 BUCKLEY HALL RD
Practice Address - Street 2:
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109-2309
Practice Address - Country:US
Practice Address - Phone:804-725-0100
Practice Address - Fax:804-725-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty