Basic Information
| Provider Information | |||||||||
| NPI: | 1083222129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID ATLANTIC LONG TERM CARE SPECIALISTS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIDEWATER INFECTIOUS DISEASE PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6160 KEMPSVILLE CIR STE 325A | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573542885 | ||||||||
| FaxNumber: | 7579175141 | ||||||||
| Practice Location | |||||||||
| Address1: | 6160 KEMPSVILLE CIR STE 325A | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573542885 | ||||||||
| FaxNumber: | 7579175141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAJIMOMENIAN | ||||||||
| AuthorizedOfficialFirstName: | AMIR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7573542885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RI0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.