Healthcare Provider Details

I. General information

NPI: 1801824479
Provider Name (Legal Business Name): MARC ROBERT GALLINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 RICHMOND HWY
LORTON VA
22079-2124
US

IV. Provider business mailing address

10105 HAMPTON WOODS DR
FAIRFAX STATION VA
22039-2729
US

V. Phone/Fax

Practice location:
  • Phone: 703-339-7788
  • Fax: 703-339-5713
Mailing address:
  • Phone: 703-643-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101027729
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: