Basic Information
| Provider Information | |||||||||
| NPI: | 1801185434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN VIRGINIA MEDICAL SCHOOL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574516200 | ||||||||
| FaxNumber: | 7574516251 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 FAIRFAX AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235072007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574516200 | ||||||||
| FaxNumber: | 7574516251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | BABASHANIAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP-ADMINISTRATION/FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7574466001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 1801185435 | 05 | VA | MEDICAID |