Provider Demographics
NPI:1912128240
Name:PEDIATRIC CENTER PC
Entity Type:Organization
Organization Name:PEDIATRIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-826-5437
Mailing Address - Street 1:901 ENTERPRISE PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-826-5437
Mailing Address - Fax:757-826-0721
Practice Address - Street 1:901 ENTERPRISE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6249
Practice Address - Country:US
Practice Address - Phone:757-826-5437
Practice Address - Fax:757-826-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006769357Medicaid
VA91788OtherBCBS
VA006769357Medicaid
VA=========OtherCHAMPUS