Provider Demographics
NPI:1770770380
Name:GENESIS AESTHETIC FACE AND VEIN SPECIALISTS, PC
Entity type:Organization
Organization Name:GENESIS AESTHETIC FACE AND VEIN SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-686-9747
Mailing Address - Street 1:1500 BREEZEPORT WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3727
Mailing Address - Country:US
Mailing Address - Phone:757-686-9747
Mailing Address - Fax:
Practice Address - Street 1:1500 BREEZEPORT WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3727
Practice Address - Country:US
Practice Address - Phone:757-686-9747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010406232086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00208779OtherRAILROAD MEDICARE
VAB06846Medicare UPIN
VAC09302Medicare PIN
VA00W168G01Medicare PIN