Provider Demographics
NPI:1205468659
Name:757 MEDICAL GROUP LC
Entity type:Organization
Organization Name:757 MEDICAL GROUP LC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:757-528-8881
Mailing Address - Street 1:21 FORREST DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1901
Mailing Address - Country:US
Mailing Address - Phone:757-528-8881
Mailing Address - Fax:757-528-8881
Practice Address - Street 1:21 FORREST DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1901
Practice Address - Country:US
Practice Address - Phone:757-528-8881
Practice Address - Fax:757-528-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-04
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty