Provider Demographics
NPI:1689731986
Name:PENINSULA PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:PENINSULA PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PITMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:757-229-5200
Mailing Address - Street 1:324 MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2834
Mailing Address - Country:US
Mailing Address - Phone:757-229-5200
Mailing Address - Fax:757-229-2692
Practice Address - Street 1:324 MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2834
Practice Address - Country:US
Practice Address - Phone:757-229-5200
Practice Address - Fax:757-229-2692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052484174400000X
208200000X, 2082S0105X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA140457OtherANTHEM
VA213427OtherCIGNA
VA121242OtherSOUTHERN HEALTH
VA620043172OtherRAILROAD MEDICARE
VA432612OtherUNITED HEALTHCARE
VA5209080OtherAETNA
VA007601328Medicaid
VA54536OtherSENTARA OPTIMA