Healthcare Provider Details

I. General information

NPI: 1710928437
Provider Name (Legal Business Name): THE PEDIATRIC GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015C MANCHESTER BLVD
ALEXANDRIA VA
22310-3253
US

IV. Provider business mailing address

7015C MANCHESTER BLVD
ALEXANDRIA VA
22310-3253
US

V. Phone/Fax

Practice location:
  • Phone: 703-971-6900
  • Fax: 703-971-9184
Mailing address:
  • Phone: 703-971-6900
  • Fax: 703-971-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA RIVERS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 703-971-6900