Basic Information
| Provider Information | |||||||||
| NPI: | 1326477506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYVIEW HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AIRLINE BOULEVARD MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8580 MAGELLAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232271149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046275462 | ||||||||
| FaxNumber: | 8664490896 | ||||||||
| Practice Location | |||||||||
| Address1: | 3537 AIRLINE BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237012650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577381225 | ||||||||
| FaxNumber: | 7574881037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2013 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUIRICONI | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8042818301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C05149 | 01 | VA | GROUP PTAN | OTHER |