Provider Demographics
NPI:1881702058
Name:FIRST COLONIAL UROLOGICAL ASS
Entity type:Organization
Organization Name:FIRST COLONIAL UROLOGICAL ASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-499-4932
Mailing Address - Street 1:4501 N WITCHDUCK RD
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455
Mailing Address - Country:US
Mailing Address - Phone:757-499-4932
Mailing Address - Fax:757-490-6693
Practice Address - Street 1:4501 B WITCHDUCK RD
Practice Address - Street 2:
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-499-4932
Practice Address - Fax:757-490-6693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101018138208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA016603OtherBC
VA7535902Medicaid
0415780001Medicare NSC
VA7535902Medicaid