Provider Demographics
NPI:1487783825
Name:UROLOGY OF VA PC
Entity type:Organization
Organization Name:UROLOGY OF VA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DELBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-466-3410
Mailing Address - Street 1:PO BOX 791254
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD STE 225
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8155
Practice Address - Country:US
Practice Address - Phone:757-934-3006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5533240008Medicare NSC