Basic Information
Provider Information
NPI: 1811957681
EntityType: 2
ReplacementNPI:  
OrganizationName: SENTARA HOSPITALS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SENTARA LEIGH HOSPITAL
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 830 KEMPSVILLE RD
Address2:  
City: NORFOLK
State: VA
PostalCode: 235023920
CountryCode: US
TelephoneNumber: 7574666000
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/24/2006
LastUpdateDate: 01/03/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BROERMANN
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: A.
AuthorizedOfficialTitleorPosition: CFO, SH
AuthorizedOfficialTelephone: 7574557020
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: SENTARA HEALTHCARE
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/03/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282N00000XH 1895VAY HospitalsGeneral Acute Care Hospital 

ID Information
IDTypeStateIssuerDescription
25060301VAHEALTHKEEPERSOTHER
656042501VAAETNAOTHER
33230301VAMAMSIOTHER
LH01VASHM ENTITYOTHER
49-0046-401VACHARTERED MEDICAIDOTHER
49-0046-405VA MEDICAID
25060301VATRIGONOTHER


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