1528103645 NPI number — STEVENSON PEDIATRICS

Table of content: (NPI 1528103645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528103645 NPI number — STEVENSON PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVENSON 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:
1528103645
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:
6000 STEVENSON AVE
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22304-3577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-823-2400
Provider Business Mailing Address Fax Number:
703-823-2013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 STEVENSON AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-3577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-823-2400
Provider Business Practice Location Address Fax Number:
703-823-2013
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DANCEL
Authorized Official First Name:
ROSARIO
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
703-823-2400

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  0101032546 , 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: 58692 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 090804 . This is a "AETNA US HEALTHCARE HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 231691 . This is a "ANTHEM HEALTH KEEPERS PLU" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 407481 . This is a "AETNA US HEALTHCARE PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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