Provider Demographics
NPI:1598042319
Name:UROLOGY OF VIRGINIA, PLLC
Entity Type:Organization
Organization Name:UROLOGY OF VIRGINIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:U
Authorized Official - Last Name:MILES-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-452-3417
Mailing Address - Street 1:225 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1815
Mailing Address - Country:US
Mailing Address - Phone:757-452-3599
Mailing Address - Fax:757-961-3696
Practice Address - Street 1:7185 HARBOUR TOWNE PKWY S STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3896
Practice Address - Country:US
Practice Address - Phone:757-457-5100
Practice Address - Fax:757-452-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2022-02-01
Deactivation Date:2018-03-05
Deactivation Code:
Reactivation Date:2018-03-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA180OtherGROUP MEDICARE PTAN
VAA180OtherGROUP MEDICARE PTAN