Basic Information
| Provider Information | |||||||||
| NPI: | 1093762361 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY IMMACULATE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 BERNARDINE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236024404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578866000 | ||||||||
| FaxNumber: | 7578866069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BERNARDINE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236024404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578866000 | ||||||||
| FaxNumber: | 7578866069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 05/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7578866758 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.