Basic Information
| Provider Information | |||||||||
| NPI: | 1881600419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT VERNON ORTHOPAEDICS ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8101 HINSON FARM RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223063403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037654321 | ||||||||
| FaxNumber: | 7037804558 | ||||||||
| Practice Location | |||||||||
| Address1: | 8101 HINSON FARM RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223063403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037654321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | BIRD | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7037654321 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 204C00000X | 0101035087 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176608 | 01 | METRO MEDICARE GROUP PTAN | OTHER | 4695 | 01 | CAREFIRST NCA GROUP PROVIDER # | OTHER | 145530100 | 01 | DEPARTMENT OF LABOR | OTHER |