MEDICARE: DERMATOLOGY ASSOCIATES OF NORTHERN VIRGINIA

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	305R00000X	Preferred Provider Organization	0101047432	VA

General Provider Information

NPI Number	:	1255791448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY ASSOCIATES OF NORTHERN VIRGINIA

Provider Business Mailing Address
First Line	:	13880 BRADDOCK RD STE 301
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20121-2462
Country	:	US
Telephone Number	:	703-222-2773
Fax Number	:	703-222-6093

Provider Business Practice Location Address
First Line	:	25055 RIDING PLZ
Second Line	:	SUITE 230
City	:	CHANTILLY
State	:	VA
Zip	:	20152-5917
Country	:	US
Telephone Number	:	703-222-2773
Fax Number	:	703-222-6093

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. ANITA JUNE NEELY
Credential	:
Telephone Number	:	703-222-2773

Provider Enumeration Date	:	03/01/2016
Last Update Date	:	03/01/2016

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