Basic Information
| Provider Information | |||||||||
| NPI: | 1194267229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY IMMACULATE HOSPITAL | ||||||||
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| OtherOrganizationName: | DBA BON SECOURS PALLIATIVE MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7007 HARBOUR VIEW BLVD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572152784 | ||||||||
| FaxNumber: | 7572152728 | ||||||||
| Practice Location | |||||||||
| Address1: | 12720 MCMANUS BLVD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236024414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579473838 | ||||||||
| FaxNumber: | 7573274280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7572152784 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VH0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Hospice and Palliative Medicine |
No ID Information.