Provider Demographics
NPI:1295044774
Name:PORTSMOUTH PEDIATRICS, PC
Entity Type:Organization
Organization Name:PORTSMOUTH PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELACRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-673-6277
Mailing Address - Street 1:446 EFFINGHAM ST.
Mailing Address - Street 2:STE. 302
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704
Mailing Address - Country:US
Mailing Address - Phone:757-673-6277
Mailing Address - Fax:757-673-6411
Practice Address - Street 1:446 EFFINGHAM ST.
Practice Address - Street 2:STE 302
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704
Practice Address - Country:US
Practice Address - Phone:757-673-6277
Practice Address - Fax:757-673-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1295044774Medicaid