Healthcare Provider's Profile
| Full Name | |
|---|
| Type | Facility |
|---|
| Speciality | Clinic/center - Multi-specialty |
|---|
| Location | 4102 Wilson Blvd, Arlington, Virginia |
|---|
| Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
|---|
NPI Data:
- NPI Number: 1790504066
- Provider Enumeration Date: 10/04/2024
- Last Update Date: 10/29/2024
Medical Identifiers
Medical identifiers for
such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1790504066 | NPI | - | NPPES |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
|---|
| 152W00000X | Optometrist | (* (Not Available)) | Secondary |
| 207VF0040X | Obstetrics & Gynecology - Female Pelvic Medicine And Reconstructive Surgery | (* (Not Available)) | Secondary |
| 207W00000X | Ophthalmology | (* (Not Available)) | Secondary |
| 208600000X | Surgery | (* (Not Available)) | Secondary |
| 208800000X | Urology | (* (Not Available)) | Secondary |
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. is NOT enrolled with medicare and thus cannot prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
|---|
6201 Greenleigh Ave,
Middle River, MD 21220-2004
Ph: (410) 933-6423 |
4102 Wilson Blvd,
Arlington, VA 22203
Ph: (703) 462-1777 |
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