1033590724 NPI number — GW THE MEDICAL FACULTY ASSOCIATE

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 1033590724 NPI number — GW THE MEDICAL FACULTY ASSOCIATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GW THE MEDICAL FACULTY ASSOCIATE
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:
1033590724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10401 GROSVENOR PL
Provider Second Line Business Mailing Address:
APT 1311
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-481-3356
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 PENNSYLVANIA AVE NW
Provider Second Line Business Practice Location Address:
DEPARTMENT OF SURGERY, SUITE 6B-412
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20037-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-741-3225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BRUCAL
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
MAGBOO
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
240-481-3356

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN1004515 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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