MEDICARE: THE MONTGOMERY MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1164013256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MONTGOMERY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3800 FAIRFAX DR STE 2
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22203-1703
Country	:	US
Telephone Number	:	703-351-5100
Fax Number	:	703-351-1445

Provider Business Practice Location Address
First Line	:	3800 FAIRFAX DR STE 2
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22203-1703
Country	:	US
Telephone Number	:	703-351-5100
Fax Number	:	703-351-1445

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. TANYA CHADWELL
Credential	:	CFNP
Telephone Number	:	703-351-5100

Provider Enumeration Date	:	02/01/2021
Last Update Date	:	02/01/2021

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