1073604435 NPI number — DR. KENNETH M BROOKS MD

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 1073604435 NPI number — DR. KENNETH M BROOKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
KENNETH
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1073604435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3023 HAMAKER CT
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-2207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-641-9161
Provider Business Mailing Address Fax Number:
703-641-0383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3023 HAMAKER CT
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22031-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-641-9161
Provider Business Practice Location Address Fax Number:
703-641-0383
Provider Enumeration Date:
09/28/2006

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: 207RC0000X , with the licence number:  0101035361 , 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: 541977219 . This is a "CIGNA PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5726 . This is a "CAREFIRST GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005842344 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 432669 . This is a "ANTHEM PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4427684 . This is a "AETNA PPOPOS PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 541977219 . This is a "NALC AFFORDABLE PROVIDER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 541977219 . This is a "MAMSI GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: C08696 . This is a "MEDICARE OF VA GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0002 . This is a "CAREFIRST PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 541977219 . This is a "UNITED HEALTHCARE PROVIDE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 541977219 . This is a "ALLIANCE GEHA GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57110 . This is a "MAMSI PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00V372C96 . This is a "MEDICARE OF VA PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 259418 . This is a "ANTHEM GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 541977219 . This is a "MDIPA GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57110 . This is a "MDIPA PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57110 . This is a "ALLIANCE GEHA PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 737485 . This is a "AETNA HMO PROVIDER #" identifier . This identifiers is of the category "OTHER".




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