1386719607 NPI number — MS. LISE ANNE GLOEDE RD

Table of content: MS. LISE ANNE GLOEDE RD (NPI 1386719607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386719607 NPI number — MS. LISE ANNE GLOEDE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOEDE
Provider First Name:
LISE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD
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:
1386719607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5275 LEE HWY
Provider Second Line Business Mailing Address:
SUITE #101
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22207-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-575-1007
Provider Business Mailing Address Fax Number:
703-358-8703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5275 LEE HWY
Provider Second Line Business Practice Location Address:
SUITE #101
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22207-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-575-1007
Provider Business Practice Location Address Fax Number:
703-358-8703
Provider Enumeration Date:
11/21/2006

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1489551 . This is a "CIGNA HEALTHCARE PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7480122 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2294420 . This is a "UNITED HEALTHCARE PROVIDE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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