Provider Demographics
NPI:1689047979
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:DBA BON SECOURS VEIN AND VASCULAR SPECIALISTS @ MIH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-215-2784
Mailing Address - Street 1:7007 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3657
Mailing Address - Country:US
Mailing Address - Phone:757-215-2784
Mailing Address - Fax:757-215-2728
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-397-2383
Practice Address - Fax:757-673-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10716Medicare PIN