Provider Demographics
NPI:1356625073
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 1:12720 MCMANUS BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4414
Mailing Address - Country:US
Mailing Address - Phone:757-947-3600
Mailing Address - Fax:757-947-3603
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-947-3600
Practice Address - Fax:757-947-3603
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY IMMACULATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-29
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10716Medicare PIN