Healthcare Provider Details

I. General information

NPI: 1740420231
Provider Name (Legal Business Name): CENTER FOR INTERVENTIONAL PAIN MANGEMENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6164 FULLER CT
ALEXANDRIA VA
22310-2540
US

IV. Provider business mailing address

6164 FULLER CT
ALEXANDRIA VA
22310-2540
US

V. Phone/Fax

Practice location:
  • Phone: 571-257-9426
  • Fax: 571-257-9839
Mailing address:
  • Phone: 571-257-9426
  • Fax: 571-257-9839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0101233817
License Number StateVA

VIII. Authorized Official

Name: TALHA SIDDIQUI
Title or Position: DIRECTOR
Credential: M.D
Phone: 804-832-3424