Provider Demographics
NPI:1750436531
Name:PENINSULA KIDNEY ASSOCIATES PC
Entity type:Organization
Organization Name:PENINSULA KIDNEY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-251-7469
Mailing Address - Street 1:501 BUTLER FARM RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1777
Mailing Address - Country:US
Mailing Address - Phone:757-251-7469
Mailing Address - Fax:757-251-7470
Practice Address - Street 1:501 BUTLER FARM RD
Practice Address - Street 2:SUITE I
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1564
Practice Address - Country:US
Practice Address - Phone:757-251-7469
Practice Address - Fax:757-251-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750436531Medicaid
VA1750436531Medicaid