1790854099 NPI number — DR. KONDEH AUGUSTA GREAVES MD DOCTOR OF MEDICIN

Table of content: DR. KONDEH AUGUSTA GREAVES MD DOCTOR OF MEDICIN (NPI 1790854099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790854099 NPI number — DR. KONDEH AUGUSTA GREAVES MD DOCTOR OF MEDICIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREAVES
Provider First Name:
KONDEH
Provider Middle Name:
AUGUSTA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD DOCTOR OF MEDICIN
Provider Gender Code:
F

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:
1790854099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 SANTMYER DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20175-5606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-220-7450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 SUDLEY RD
Provider Second Line Business Practice Location Address:
PRINCE WILLIAM HOSPITAL
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-396-5284
Provider Business Practice Location Address Fax Number:
703-396-8051
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  0101234737 , 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: 010036534 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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