1174544399 NPI number — DR. LISA RAINEY M.D.

Table of content: DR. LISA RAINEY M.D. (NPI 1174544399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174544399 NPI number — DR. LISA RAINEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAINEY
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174544399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4600 DUKE ST
Provider Second Line Business Mailing Address:
SUITE 332
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22304-2552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-823-7400
Provider Business Mailing Address Fax Number:
703-823-5814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 DUKE ST
Provider Second Line Business Practice Location Address:
SUITE 332
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-823-7400
Provider Business Practice Location Address Fax Number:
703-823-5814
Provider Enumeration Date:
07/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  D0055310 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 217436 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006705111 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".