Healthcare Provider Details

I. General information

NPI: 1942883764
Provider Name (Legal Business Name): MCLEAN TYSONS ORTHOPEDIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 OLD MEADOW RD
MC LEAN VA
22102-4331
US

IV. Provider business mailing address

1760 OLD MEADOW RD
MC LEAN VA
22102-4331
US

V. Phone/Fax

Practice location:
  • Phone: 860-667-9542
  • Fax:
Mailing address:
  • Phone: 860-667-9542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUCILLE FORMEISTER
Title or Position: DIR. BUS SYSTEMS
Credential:
Phone: 860-667-9542