Provider Demographics
NPI:1477766020
Name:MID-ATLANTIC FAMILY PRACTICE
Entity Type:Organization
Organization Name:MID-ATLANTIC FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-460-2171
Mailing Address - Street 1:1020 INDEPENDENCE BLVD
Mailing Address - Street 2:#103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5500
Mailing Address - Country:US
Mailing Address - Phone:757-460-2171
Mailing Address - Fax:
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:#103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-460-2171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047049207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACK8605OtherMEDICARE RAILROAD
VA292836OtherANTHEM BCBS
VA298394OtherMAMSI
60522OtherOPTIMA
VA1669473260OtherPROVIDER NPI
VA2944020OtherAETNA/US HEALTHCARE
VA005645697Medicaid
60522OtherOPTIMA
VACO8587Medicare ID - Type UnspecifiedCOMPANY BILLING NUMBER
VA005645697Medicaid
VAC08587Medicare PIN