Healthcare Provider Details

I. General information

NPI: 1164013256
Provider Name (Legal Business Name): THE MONTGOMERY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 FAIRFAX DR STE 2
ARLINGTON VA
22203-1703
US

IV. Provider business mailing address

3800 FAIRFAX DR STE 2
ARLINGTON VA
22203-1703
US

V. Phone/Fax

Practice location:
  • Phone: 703-351-5100
  • Fax: 703-351-1445
Mailing address:
  • Phone: 703-351-5100
  • Fax: 703-351-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANYA CHADWELL
Title or Position: CLINICAL DIRECTOR
Credential: CFNP
Phone: 703-351-5100