Basic Information
| Provider Information | |||||||||
| NPI: | 1598042319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY OF VIRGINIA, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CLEARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | VA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574523599 | ||||||||
| FaxNumber: | 7579613696 | ||||||||
| Practice Location | |||||||||
| Address1: | 7185 HARBOUR TOWNE PKWY S STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575100 | ||||||||
| FaxNumber: | 7574523402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/05/2018 | ||||||||
| NPIReactivationDate: | 03/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILES-THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | U | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7574523417 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | A180 | 01 | VA | GROUP MEDICARE PTAN | OTHER |