1811057102 NPI number — ANNANDALE OB GYN

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 1811057102 NPI number — ANNANDALE OB GYN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANNANDALE OB GYN
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:
1811057102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRIFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22116-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-642-7522
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4208 EVERGREEN LN
Provider Second Line Business Practice Location Address:
STE 213
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-642-7522
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LE
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
NHA-KHANH
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
703-642-7522

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 010179785 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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