Provider Demographics
NPI:1619660883
Name:MINORITY AIDS SUPPORT SERVICES INC
Entity Type:Organization
Organization Name:MINORITY AIDS SUPPORT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS-WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:757-586-5243
Mailing Address - Street 1:2715 HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-3913
Mailing Address - Country:US
Mailing Address - Phone:757-240-4363
Mailing Address - Fax:
Practice Address - Street 1:247 28TH ST STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607-3907
Practice Address - Country:US
Practice Address - Phone:757-586-5243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty