Basic Information
| Provider Information | |||||||||
| NPI: | 1760400337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3650 | ||||||||
| Address2: | |||||||||
| City: | MERRIFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221163650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7035730880 | ||||||||
| Practice Location | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7035730880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 0101235813 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 0101235813 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 0100059526 | 05 | VA | MEDICAID | 0075 | 01 | VA | CAREFIRST | OTHER | 20042310000 | 05 | MD | MEDICAID | 7441630 | 01 | VA | AETNA PPO | OTHER | 3677450 | 01 | VA | AETNA HMO | OTHER |