Provider Demographics
NPI:1619016284
Name:GREATER SUFFOLK MEDICAL CENTER
Entity Type:Organization
Organization Name:GREATER SUFFOLK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-934-1003
Mailing Address - Street 1:114 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4564
Mailing Address - Country:US
Mailing Address - Phone:757-934-1003
Mailing Address - Fax:757-934-1660
Practice Address - Street 1:114 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4564
Practice Address - Country:US
Practice Address - Phone:757-934-1003
Practice Address - Fax:757-934-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12068OtherOPTIMA
NC77906536Medicaid
VA110007205Medicaid
VA45055OtherOPTIMA
NC890658EMedicaid
VA13762OtherOPTIMA
VA095436OtherBLUE CROSS
VI5813735Medicaid
NC7360720Medicaid
VI6068286Medicaid
VA041021OtherBLUE CROSS
VA12104OtherOPTIMA
NC7906203Medicaid
VA12068OtherOPTIMA
NC7360720Medicaid
VA45055OtherOPTIMA
VA110007205Medicaid
VA110198585Medicare PIN
VAB06737Medicare UPIN
VAB06032Medicare UPIN
VA020046044Medicare PIN
VA12104OtherOPTIMA
VAG77617Medicare UPIN
VA110056242Medicare PIN
VA020000321Medicare PIN