Healthcare Provider Details

I. General information

NPI: 1790912566
Provider Name (Legal Business Name): GI ENDOSCOPY CENTER OF NORTHERN VIRGINIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE SUITE 100
ALEXANDRIA VA
22304-1313
US

IV. Provider business mailing address

PO BOX 17334
BALTIMORE MD
21297-1334
US

V. Phone/Fax

Practice location:
  • Phone: 703-751-5763
  • Fax: 703-370-4655
Mailing address:
  • Phone: 703-443-6717
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY BETH TAMASY
Title or Position: CEO
Credential:
Phone: 703-737-6010