1689769861 NPI number — NORTHERN VIRGINIA UROLOGY, PLLC

Table of content: (NPI 1689769861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689769861 NPI number — NORTHERN VIRGINIA UROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN VIRGINIA UROLOGY, PLLC
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:
1689769861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10301 DEMOCRACY LN
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-2545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-876-5942
Provider Business Mailing Address Fax Number:
703-876-5972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 DEMOCRACY LN
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-2545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-876-5942
Provider Business Practice Location Address Fax Number:
703-876-5972
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENNA
Authorized Official First Name:
MARYJO
Authorized Official Middle Name:
MAYBERRY
Authorized Official Title or Position:
CENTRAL BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
703-876-5942

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1689769861 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1220932 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: N190 . This is a "CAREFIRST BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7845793 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com