Provider Demographics
NPI:1770678450
Name:INDEPENDENCE FAMILY MEDICINE
Entity Type:Organization
Organization Name:INDEPENDENCE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:MORO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-333-7625
Mailing Address - Street 1:813 INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6004
Mailing Address - Country:US
Mailing Address - Phone:757-333-7625
Mailing Address - Fax:757-333-7639
Practice Address - Street 1:813 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6004
Practice Address - Country:US
Practice Address - Phone:757-333-7625
Practice Address - Fax:757-333-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09188Medicare PIN