1285832535 NPI number — LANDMARK INTERNAL MEDICINE, LLC

Table of content: (NPI 1285832535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285832535 NPI number — LANDMARK INTERNAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANDMARK INTERNAL MEDICINE, 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:
1285832535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2646
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-0646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-323-0589
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6300 STEVENSON AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-3576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-370-0778
Provider Business Practice Location Address Fax Number:
703-212-7083
Provider Enumeration Date:
07/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
703-370-0785

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101230358 , 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: DA3798 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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