Healthcare Provider Details

I. General information

NPI: 1215376025
Provider Name (Legal Business Name): GYNE HEALTH OBSTETRICS & GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 DUKE ST
ALEXANDRIA VA
22314-4512
US

IV. Provider business mailing address

9202 SILVEROSE CT
FAIRFAX STATION VA
22039-3116
US

V. Phone/Fax

Practice location:
  • Phone: 401-419-5998
  • Fax:
Mailing address:
  • Phone: 401-419-5998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101244682
License Number StateVA

VIII. Authorized Official

Name: DR. ETEAKAMBA UDOH
Title or Position: DIRECTOR
Credential: MD
Phone: 401-419-5998