Basic Information
| Provider Information | |||||||||
| NPI: | 1588215032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONE RIDGE FAMILY MEDICINE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42619 KELLAMUGH TER | ||||||||
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| City: | CHANTILLY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201526082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156011768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24560 SOUTHPOINT DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | ALDIE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201053504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156010174 | ||||||||
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| ProviderEnumerationDate: | 09/26/2019 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHIRSOLKAR | ||||||||
| AuthorizedOfficialFirstName: | PRADNYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3156010174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.