Healthcare Provider Details

I. General information

NPI: 1932447463
Provider Name (Legal Business Name): HEALTH CONNECT IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 LEE JACKSON MEMORIAL HWY SUITE 504
FAIRFAX VA
22033-3310
US

IV. Provider business mailing address

12011 LEE JACKSON MEMORIAL HWY SUITE 504
FAIRFAX VA
22033-3310
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-2042
  • Fax: 703-273-3943
Mailing address:
  • Phone: 703-391-2042
  • Fax: 703-273-3943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURI RUSTAND
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 703-391-2042