Provider Demographics
NPI:1811101439
Name:SENTARA OBICI AMBULATORY SURGERY, LLC
Entity type:Organization
Organization Name:SENTARA OBICI AMBULATORY SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERTZLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-983-2009
Mailing Address - Street 1:2750 GODWIN BLVD.
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-983-2000
Mailing Address - Fax:757-983-2001
Practice Address - Street 1:2750 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-983-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1811101439Medicaid
VA1811101439Medicaid