1700802097 NPI number — YUILL BLACK MD AND MICHAEL R KLETZ MD PC

Table of content: (NPI 1700802097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700802097 NPI number — YUILL BLACK MD AND MICHAEL R KLETZ MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YUILL BLACK MD AND MICHAEL R KLETZ MD 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:
6
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:
1700802097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 SPRING HILL RD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
MCLEAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22102-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-790-9722
Provider Business Mailing Address Fax Number:
703-893-8666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 SPRING HILL RD
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
MCLEAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22102-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-790-9722
Provider Business Practice Location Address Fax Number:
703-893-8666
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEVOL
Authorized Official First Name:
CHARLENE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
703-790-9675

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: CD8485 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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