Provider Demographics
NPI:1609110774
Name:MID-ATLANTIC WOMENS CARE PLC
Entity Type:Organization
Organization Name:MID-ATLANTIC WOMENS CARE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:G
Authorized Official - Last Name:WATERBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-461-3890
Mailing Address - Street 1:828 HEALTHY WAY
Mailing Address - Street 2:SUITE 330
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7958
Mailing Address - Country:US
Mailing Address - Phone:757-461-3890
Mailing Address - Fax:757-467-0301
Practice Address - Street 1:828 HEALTHY WAY
Practice Address - Street 2:SUITE 330
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7958
Practice Address - Country:US
Practice Address - Phone:757-461-3890
Practice Address - Fax:757-467-0301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-ATLANTIC WOMENS CARE PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1701004447101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05062OtherC05062