Provider Demographics
NPI:1467580472
Name:PENINSULA WILLIAMSBURG CARDIOLOGY ASSOC
Entity Type:Organization
Organization Name:PENINSULA WILLIAMSBURG CARDIOLOGY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-875-5332
Mailing Address - Street 1:12720 MCMANUS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4414
Mailing Address - Country:US
Mailing Address - Phone:757-875-5332
Mailing Address - Fax:787-874-1545
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-875-5332
Practice Address - Fax:787-874-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036628207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09393Medicare PIN