Healthcare Provider Details

I. General information

NPI: 1699119818
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 HAMAKER CT SUITE 200
FAIRFAX VA
22031-2207
US

IV. Provider business mailing address

3023 HAMAKER CT SUITE 200
FAIRFAX VA
22031-2207
US

V. Phone/Fax

Practice location:
  • Phone: 703-848-6627
  • Fax:
Mailing address:
  • Phone: 703-848-6627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARGARET C HARRIS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 703-848-6630