Healthcare Provider Details

I. General information

NPI: 1023232345
Provider Name (Legal Business Name): THE PEDIATRIC GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 CENTREVILLE ROAD
CHANTILLY VA
20151
US

IV. Provider business mailing address

7015 C MANCHESTER BLVD.
ALEXANDRIA VA
22310
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GRADER
Title or Position: ADMINISTRATOR
Credential:
Phone: 703-971-6900