Basic Information
| Provider Information | |||||||||
| NPI: | 1013971126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN VIRGINIA PATHOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100559 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436464300 | ||||||||
| FaxNumber: | 8436464308 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033913654 | ||||||||
| FaxNumber: | 7033913049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | WERNESS | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7033913654 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | MD0101042785 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 0101049095 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 187030 | 01 | VA | BCBS | OTHER |