Basic Information
| Provider Information | |||||||||
| NPI: | 1992103568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MGMC, LLC | ||||||||
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| OtherOrganizationName: | MEDSTAR GEORGETOWN ORTHO INST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 15TH ST N | ||||||||
| Address2: | STE 600 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222012683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888961400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6355 WALKER LN | ||||||||
| Address2: | STE 501 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039713701 | ||||||||
| FaxNumber: | 7039710958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2014 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCHNEIDER | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7035581403 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MGMC, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.