Healthcare Provider Details

I. General information

NPI: 1679199194
Provider Name (Legal Business Name): ABYSSINIA MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE STE 200
ALEXANDRIA VA
22304-1306
US

IV. Provider business mailing address

4660 KENMORE AVE STE 200
ALEXANDRIA VA
22304-1306
US

V. Phone/Fax

Practice location:
  • Phone: 703-957-9749
  • Fax:
Mailing address:
  • Phone: 703-957-9749
  • Fax: 703-717-0578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELAT BAYE
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 703-944-7580