Basic Information
| Provider Information | |||||||||
| NPI: | 1235205147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA HOSPITALS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENTARA NIGHTINGALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 POPLAR HALL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574557102 | ||||||||
| FaxNumber: | 7574557919 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROERMANN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7574557020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SENTARA HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416A0800X | VA | Y | Transportation Services | Ambulance | Air Transport |
ID Information
| ID | Type | State | Issuer | Description | 9020063 | 05 | VA | MEDICAID |