Healthcare Provider Details

I. General information

NPI: 1023063112
Provider Name (Legal Business Name): MOUNT VERNON REHABILITATION MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 PARKERS LN
ALEXANDRIA VA
22306-3209
US

IV. Provider business mailing address

PO BOX 829
ALEXANDRIA VA
22304
US

V. Phone/Fax

Practice location:
  • Phone: 703-664-7568
  • Fax: 410-793-0809
Mailing address:
  • Phone: 703-664-7568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: ROGER GISOLFI
Title or Position: CHAIRMAN
Credential: M.D.
Phone: 703-664-7568