Basic Information
| Provider Information | |||||||||
| NPI: | 1881848091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVMS ACADEMIC PHYSICIANS AND SURGEONS HEALTH SERVICES FOUNDATION | ||||||||
| LastName: | |||||||||
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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: | 7573883483 | ||||||||
| FaxNumber: | 7576270334 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883483 | ||||||||
| FaxNumber: | 7576270334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | LIND | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7574516200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.