1538394861 NPI number — PW UROLOGY OBS LLC

Table of content: (NPI 1538394861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538394861 NPI number — PW UROLOGY OBS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PW UROLOGY OBS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1538394861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9580 SURVEYOR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-4406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-361-4129
Provider Business Mailing Address Fax Number:
703-361-9442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9580 SURVEYOR CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-361-4129
Provider Business Practice Location Address Fax Number:
703-361-9442
Provider Enumeration Date:
05/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SAJADI
Authorized Official First Name:
ALI
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
703-361-4129

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4274185 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7510306 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7685401 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 87830005 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7966591 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 87830004 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 281216 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 306085 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 014761 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 182822 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010198976 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87830002 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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