Organization
MARY IMMACULATE AMBULATORY SURGERY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KRISTEN OCONNOR (AUTHORIZED OFFICIAL)
(615) 376-7315
Entity
Organization
Contact information
Practice address
12720 MCMANUS BLVD, STE 103, NEWPORT NEWS, VA 23602-4441
(757) 369-7000
(757) 369-3465
Mailing address
12720 MCMANUS BLVD, STE 103, NEWPORT NEWS, VA 23602-4441
(757) 369-7000
(757) 369-3465
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
OH686
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010113181
—
VA
01
—
P00165787
MEDICARE RAILROAD
VA
Enumeration date
07/04/2006
Last updated
10/11/2024
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