Basic Information
| Provider Information | |||||||||
| NPI: | 1174812192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | SLEDD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SLEDD | ||||||||
| OtherFirstName: | ALEXANDRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 FAIRFAX AVE | ||||||||
| Address2: | STE 118 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101260428 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1174812192 | 01 | VA | UNITED HEALTHCARE | OTHER | 1174812192 | 01 | VA | MULTIPLAN | OTHER | 1174812192 | 01 | VA | COVENTRY HEALTH CARE | OTHER | 1174812192 | 05 | NC | MEDICAID | 1174812192 | 01 | VA | CORVEL | OTHER | 1174812192 | 01 | VA | VIRGINIA PREMIER HEALTH PLAN | OTHER | 1174812192 | 01 | VA | OPTIMA HEALTH | OTHER | 1174812192 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1174812192 | 01 | VA | HUMANA | OTHER | 1174812192 | 01 | VA | USA MANAGED CARE | OTHER | 1174812192 | 01 | VA | AETNA | OTHER | 1174812192 | 01 | VA | ANTHEM BC/BS | OTHER | 1174812192 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 1174812192 | 05 | VA | MEDICAID | 1174812192 | 01 | VA | CIGNA | OTHER |