| Cleanslate Medical Group Of Virginia, Llc | |
|
160 Kingsley Ln Ste 303 Norfolk VA 23505-4600 | |
| (413) 584-2173 | |
| Not Available |
| Full Name | Cleanslate Medical Group Of Virginia, Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 160 Kingsley Ln Ste 303, Norfolk, Virginia |
| Authorized Official Name and Position | Robert Hutchison (CFO) |
| Authorized Official Contact | 6154250220 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Cleanslate Medical Group Of Virginia, Llc 12 Cadillac Dr Ste 380 Brentwood TN 37027-5272 Ph: () - | Cleanslate Medical Group Of Virginia, Llc 160 Kingsley Ln Ste 303 Norfolk VA 23505-4600 Ph: (413) 584-2173 |
| NPI Number | 1629549779 |
|---|---|
| Provider Enumeration Date | 12/16/2018 |
| Last Update Date | 07/02/2019 |
| Medicare PECOS PAC ID | 9133462294 |
|---|---|
| Medicare Enrollment ID | O20190514000779 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629549779 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Secondary |
| 207RA0401X | Internal Medicine - Addiction Medicine | (* (Not Available)) | Primary |
| Provider Name | Shannon R Davidson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053571562 PECOS PAC ID: 0446430383 Enrollment ID: I20110209000375 |
| Provider Name | Bishoy T Samuel |
|---|---|
| Provider Type | Practitioner - Addiction Medicine |
| Provider Identifiers | NPI Number: 1659506624 PECOS PAC ID: 4880902915 Enrollment ID: I20221122000425 |
| Provider Name | Parth A Saraiya |
|---|---|
| Provider Type | Practitioner - Preventive Medicine |
| Provider Identifiers | NPI Number: 1124482583 PECOS PAC ID: 3971897299 Enrollment ID: I20230315000869 |
| Provider Name | Tipree D Graves |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1780469429 PECOS PAC ID: 1254782691 Enrollment ID: I20240110000490 |
| Provider Name | Melissa R King |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1578269940 PECOS PAC ID: 0446601561 Enrollment ID: I20240112001403 |
| Provider Name | Satkiran Grewal |
|---|---|
| Provider Type | Practitioner - Addiction Medicine |
| Provider Identifiers | NPI Number: 1356421085 PECOS PAC ID: 3678592060 Enrollment ID: I20240208004628 |
| Provider Name | Edward W Berry |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1336700129 PECOS PAC ID: 7315383536 Enrollment ID: I20240311002232 |
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