Provider Demographics
NPI:1831196872
Name:WILLIAMSBURG NEUROLOGY, P.C.
Entity type:Organization
Organization Name:WILLIAMSBURG NEUROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRAINARD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:757-345-3907
Mailing Address - Street 1:120 KINGS WAY
Mailing Address - Street 2:SUITE 2700
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2505
Mailing Address - Country:US
Mailing Address - Phone:757-221-0110
Mailing Address - Fax:757-221-0851
Practice Address - Street 1:120 KINGS WAY
Practice Address - Street 2:SUITE 2700
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2505
Practice Address - Country:US
Practice Address - Phone:757-221-0110
Practice Address - Fax:757-221-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048000174400000X
VA0101052740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6104215Medicaid
VA270420OtherANTHEM GROUP NUMBER
VA322877OtherHARDING-ANTHEM BCBS
VA84282OtherHARDING-SOUTHERN HEALTH
VA95834OtherSOUEIDAN-SOUTHERN HEALTH
VA6154085Medicaid
VA270421OtherSOUEIDAN-ANTHEM BCBS
VA45061OtherSOUEIDAN-SENTARA PROVIDER
VA54560OtherHARDING-SENTARA PROVIDERU
VA54560OtherHARDING-SENTARA PROVIDERU
VABS3178868OtherSOUEIDAN DEA NUMBER
VA95834OtherSOUEIDAN-SOUTHERN HEALTH
VABS3178868OtherSOUEIDAN DEA NUMBER
VA6154085Medicaid
VAG47498Medicare UPIN