Healthcare Provider Details

I. General information

NPI: 1114018249
Provider Name (Legal Business Name): BRISTOW RUN FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 JOHN MARSHALL HWY SUITE 104
GAINESVILLE VA
20155-1691
US

IV. Provider business mailing address

14540 JOHN MARSHALL HWY SUITE 104
GAINESVILLE VA
20155-1691
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-9799
  • Fax: 703-753-9792
Mailing address:
  • Phone: 703-753-9799
  • Fax: 703-753-9792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101230910
License Number StateVA

VIII. Authorized Official

Name: DR. STEVEN J TANG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-753-9799