Healthcare Provider Details

I. General information

NPI: 1023719366
Provider Name (Legal Business Name): CROSSOVER MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6922 LITTLE RIVER TURNPIKE SUITE D
ANNADALE VA
22003
US

IV. Provider business mailing address

6922 LITTLE RIVER TURNPIKE SUITE D
ANNADALE VA
22003
US

V. Phone/Fax

Practice location:
  • Phone: 703-705-9306
  • Fax: 703-890-3114
Mailing address:
  • Phone: 703-705-9306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROTIMI ADEGOKE ILUYOMADE
Title or Position: MEDICAL DIRECTOR/CEO
Credential: M.D.
Phone: 301-379-7736