Healthcare Provider Details

I. General information

NPI: 1356601058
Provider Name (Legal Business Name): INTERNAL MEDICINE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 WOODBURN RD SUITE 304
ANNANDALE VA
22003-1229
US

IV. Provider business mailing address

4034 CAIRO PL
WOODBRIDGE VA
22192-7616
US

V. Phone/Fax

Practice location:
  • Phone: 703-204-0355
  • Fax: 703-204-0356
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102202240
License Number StateVA

VIII. Authorized Official

Name: DR. TAHIR SHAIKH
Title or Position: DIRECTOR
Credential: DO, MBBS
Phone: 703-204-0355