Provider Demographics
NPI:1265715932
Name:MARY IMMACULATE HOSPITAL
Entity type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-673-5929
Mailing Address - Street 1:500 SENTARA CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5727
Mailing Address - Country:US
Mailing Address - Phone:757-984-9890
Mailing Address - Fax:757-345-6659
Practice Address - Street 1:500 SENTARA CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5727
Practice Address - Country:US
Practice Address - Phone:757-984-9890
Practice Address - Fax:757-345-6659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY IMMACULATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-20
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10716Medicare PIN