Healthcare Provider Details

I. General information

NPI: 1780851204
Provider Name (Legal Business Name): GASTROINTESTINAL MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 JOSEPH SIEWICK DR 401
FAIRFAX VA
22033-1744
US

IV. Provider business mailing address

3700 JOSEPH SIEWICK DR 401
FAIRFAX VA
22033-1744
US

V. Phone/Fax

Practice location:
  • Phone: 703-281-1023
  • Fax: 703-620-2331
Mailing address:
  • Phone: 703-281-1023
  • Fax: 703-620-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0637509
License Number StateVA

VIII. Authorized Official

Name: GRETTA HERBERT
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 703-281-1023