Healthcare Provider Details

I. General information

NPI: 1609600303
Provider Name (Legal Business Name): MID ATLANTIC MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10604 ROSEHAVEN ST
FAIRFAX VA
22030-2825
US

IV. Provider business mailing address

10604 ROSEHAVEN ST
FAIRFAX VA
22030-2825
US

V. Phone/Fax

Practice location:
  • Phone: 703-627-9930
  • Fax:
Mailing address:
  • Phone: 703-627-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAFEEK SEDDIQ
Title or Position: MEMBER
Credential: ESQ.
Phone: 703-677-6394