1356432934 NPI number — PEDIATRIC ASSOCIATES OF NORTHERN VIRGINIA, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356432934 NPI number — PEDIATRIC ASSOCIATES OF NORTHERN VIRGINIA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES OF NORTHERN VIRGINIA, P.C.
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:
OLDE TOWNE PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1356432934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9324 WEST ST
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-5138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-365-0227
Provider Business Mailing Address Fax Number:
703-365-0332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9324 WEST ST
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-5138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-365-0227
Provider Business Practice Location Address Fax Number:
703-365-0332
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ANASTASIA
Authorized Official Middle Name:
LONGCHAMPS
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
703-365-0227

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  06-00006304 , 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)





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