Healthcare Provider Details

I. General information

NPI: 1275501736
Provider Name (Legal Business Name): BRYAN WALLACE MCEACHERN M.D., F.A.A.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 DIGGES RD SUITE 106
MANASSAS VA
20110-4421
US

IV. Provider business mailing address

9001 DIGGES RD SUITE 106
MANASSAS VA
20110-4421
US

V. Phone/Fax

Practice location:
  • Phone: 703-392-5437
  • Fax: 703-392-0176
Mailing address:
  • Phone: 703-392-5437
  • Fax: 703-392-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101051497
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: