Basic Information
Provider Information | |||||||||
NPI: | 1558739748 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MGMC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDSTAR ORTHOPAEDIC INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 15TH ST N | ||||||||
Address2: | SUITE 600 | ||||||||
City: | ARLINGTON | ||||||||
State: | VA | ||||||||
PostalCode: | 222012683 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888961400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6858 OLD DOMINION DR | ||||||||
Address2: | SECOND FLOOR | ||||||||
City: | MC LEAN | ||||||||
State: | VA | ||||||||
PostalCode: | 221013899 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2022950549 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2015 | ||||||||
LastUpdateDate: | 09/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHNEIDER | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 7035581403 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MGMC, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.