Basic Information
| Provider Information | |||||||||
| NPI: | 1922048230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEXANDRIA PERINATAL DIAGNOSTIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2876 GUARDIAN LANE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234527327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574635240 | ||||||||
| FaxNumber: | 7574636572 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 SEMINARY ROAD | ||||||||
| Address2: | INOVA ALEXANDRIA HOSPITAL DIAGNOSTIC CENTER | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035047868 | ||||||||
| FaxNumber: | 7035047733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOZLOFF | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR INOVA ALEXANDRIA HOSP | ||||||||
| AuthorizedOfficialTelephone: | 7035043167 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207SC0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Cytogenetic | 207VM0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2504 | 01 | VA | CAREFIRST | OTHER |