Provider Demographics
NPI:1972909497
Name:PENINSULA PATHOLOGY ASSOCIATES OF VIRGINIA PLLC
Entity Type:Organization
Organization Name:PENINSULA PATHOLOGY ASSOCIATES OF VIRGINIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-594-2867
Mailing Address - Street 1:PO BOX 19100
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-1010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054006207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty