Provider Demographics
NPI:1720159270
Name:PENINSULA SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PENINSULA SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:GORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-827-2040
Mailing Address - Street 1:4000 COLISEUM DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5906
Mailing Address - Country:US
Mailing Address - Phone:757-827-2040
Mailing Address - Fax:757-827-2055
Practice Address - Street 1:4000 COLISEUM DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5906
Practice Address - Country:US
Practice Address - Phone:757-827-2040
Practice Address - Fax:757-827-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7301511Medicaid
VAB09264Medicare UPIN