Provider Demographics
NPI:1316193741
Name:MARYVIEW HOSPITAL
Entity Type:Organization
Organization Name:MARYVIEW HOSPITAL
Other - Org Name:EAGLE HARBOR MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIRICONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-8301
Mailing Address - Street 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:804-627-5462
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:13609 CARROLLTON BLVD STE 11
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3214
Practice Address - Country:US
Practice Address - Phone:757-238-8751
Practice Address - Fax:757-238-8750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVIEW HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-18
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACC4075Medicare PIN
VAGC1103Medicare PIN