Provider Demographics
NPI:1346270329
Name:MARY IMMACULATE AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:MARY IMMACULATE AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:12720 MCMANUS BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4441
Mailing Address - Country:US
Mailing Address - Phone:757-369-7000
Mailing Address - Fax:757-369-3465
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:STE 103
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4441
Practice Address - Country:US
Practice Address - Phone:757-369-7000
Practice Address - Fax:757-369-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH686261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010113181Medicaid
VAP00165787OtherMEDICARE RAILROAD
VA010113181Medicaid