Healthcare Provider Details

I. General information

NPI: 1932199676
Provider Name (Legal Business Name): LYDIA HAILE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD ALEXANDRIA HOSPITAL
ALEXANDRIA VA
22304
US

IV. Provider business mailing address

20010 CENTURY BLVD STE 200
GERMANTOWN MD
20874-1115
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-3066
  • Fax: 703-504-3866
Mailing address:
  • Phone: 240-686-2300
  • Fax: 240-686-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101231495
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: