Healthcare Provider Details

I. General information

NPI: 1174979587
Provider Name (Legal Business Name): TAALIBA AL-ALIM SAHIB JR. AG ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MCCORMICK FARM DR UNIT B
GLEN ALLEN VA
23060-4035
US

IV. Provider business mailing address

100 HOSPITAL RD
PRINCE FREDERICK MD
20678-4017
US

V. Phone/Fax

Practice location:
  • Phone: 757-214-3998
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024175434
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN228237
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAC004504
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: