Basic Information
Provider Information | |||||||||
NPI: | 1497712756 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAMPTON ROADS PATHOLOGY INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1295 | ||||||||
Address2: |   | ||||||||
City: | BLUEFIELD | ||||||||
State: | WV | ||||||||
PostalCode: | 247011295 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043234320 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 736 BATTLEFIELD BLVD N | ||||||||
Address2: | CHESAPEAKE GENERAL HOSPITAL | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233204906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7573128121 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2006 | ||||||||
LastUpdateDate: | 11/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACOB | ||||||||
AuthorizedOfficialFirstName: | LIONEL | ||||||||
AuthorizedOfficialMiddleName: | NEWMAN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7573128121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 890179J | 05 | NC |   | MEDICAID | 0179J | 01 | NC | BCBS NC | OTHER | C03497 | 01 |   | RAILROAD MEDICARE | OTHER |