1205034659 NPI number — PEDIATRIC PRACTICE,PC

Table of content: (NPI 1205034659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205034659 NPI number — PEDIATRIC PRACTICE,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PRACTICE,PC
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:
1205034659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/27/2020
NPI Reactivation Date:
04/19/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5131 PLEASANT FOREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTREVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20120-1249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-803-3282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8600 ROLLING RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-3868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-361-3870
Provider Business Practice Location Address Fax Number:
703-361-3871
Provider Enumeration Date:
07/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAMBA
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-361-3870

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101222057 , 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: 006702015 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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