Healthcare Provider Details

I. General information

NPI: 1649150590
Provider Name (Legal Business Name): WILLIAM GLENN IVEY III CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 10/24/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

IV. Provider business mailing address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-3000
  • Fax:
Mailing address:
  • Phone: 703-504-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number5782
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: