Basic Information
| Provider Information | |||||||||
| NPI: | 1528028396 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA PRINCESS ANNE HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENTARA HOSPITALS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| 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: | 2025 GLENN MITCHELL DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234560178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575071000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROERMANN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7574557020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SENTARA HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H 1893 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010576 | 01 | VA | HEALTHKEEPERS | OTHER | 6560685 | 01 | VA | AETNA | OTHER | 010576 | 01 | VA | TRIGON | OTHER | BS | 01 | VA | SHM ENTITY | OTHER | 49-0119-3 | 05 | VA | MEDICAID | 541547408 | 01 | VA | OTHERS | OTHER | 232300 | 01 | VA | MAMSI | OTHER | 49-0119-3 | 01 | VA | CHARTERED MEDICAID | OTHER | 541547408 | 01 | VA | TRICARE | OTHER |