Basic Information
| Provider Information | |||||||||
| NPI: | 1518376086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVMS ACADEMIC PHYSICIANS AND SURGEONS HEALTH SERVICES FOUNDATION | ||||||||
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| OtherOrganizationName: | EVMS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | EVMS MEDICAL GROUP | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465629 | ||||||||
| FaxNumber: | 7574466000 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 FAIRFAX AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235072007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465629 | ||||||||
| FaxNumber: | 7574466000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2014 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | LIND | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7574516266 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.