Basic Information
| Provider Information | |||||||||
| NPI: | 1770536724 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST INTERNISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 487 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221010487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033562037 | ||||||||
| FaxNumber: | 7037348987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 DOLLEY MADISON BLVD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033562037 | ||||||||
| FaxNumber: | 7037348987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | MASTERSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7033562037 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101038350 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101038350 | 01 | VA | MEDICAL LICENSE | OTHER |