1649215955 NPI number — ALEXANDRIA LAKE RIDGE PEDIATRICS

Table of content: (NPI 1649215955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649215955 NPI number — ALEXANDRIA LAKE RIDGE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEXANDRIA LAKE RIDGE PEDIATRICS
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:
1649215955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 N BEAUREGARD ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22311-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-436-1200
Provider Business Mailing Address Fax Number:
703-499-9670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 N BEAUREGARD ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22311-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-436-1200
Provider Business Practice Location Address Fax Number:
703-499-9670
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOFFER
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL ADMINISTRTOR
Authorized Official Telephone Number:
703-436-1200

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  101038289 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6721001 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6719694 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6733816 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6792896 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6738214 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6704999 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010077036 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6738206 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6737935 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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