Provider Demographics
NPI:1801185434
Name:EASTERN VIRGINIA MEDICAL SCHOOL
Entity Type:Organization
Organization Name:EASTERN VIRGINIA MEDICAL SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP-ADMINISTRATION/FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BABASHANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-446-6001
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-451-6200
Mailing Address - Fax:757-451-6251
Practice Address - Street 1:721 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-2007
Practice Address - Country:US
Practice Address - Phone:757-451-6200
Practice Address - Fax:757-451-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1801185435Medicaid
VAA164Medicare PIN