Healthcare Provider Details

I. General information

NPI: 1982010302
Provider Name (Legal Business Name): VIRGINIA CARDIOVASCULAR GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19450 DEERFIELD AVE STE 335
LEESBURG VA
20176-6820
US

IV. Provider business mailing address

19450 DEERFIELD AVE STE 335
LEESBURG VA
20176-6820
US

V. Phone/Fax

Practice location:
  • Phone: 703-939-9942
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number0101237500
License Number StateVA

VIII. Authorized Official

Name: TAREK ABOU GHAZALA
Title or Position: PRESIDENT
Credential: MD
Phone: 703-939-9942