Healthcare Provider Details

I. General information

NPI: 1710711973
Provider Name (Legal Business Name): ALLY MEDICAL GROUP, P.A. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 SPRING HILL RD STE 305
MC LEAN VA
22102-3020
US

IV. Provider business mailing address

1410 SPRING HILL RD STE 305
MC LEAN VA
22102-3020
US

V. Phone/Fax

Practice location:
  • Phone: 240-342-2666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LORRAINE KABAKAMA BERAHO
Title or Position: DIRECTOR
Credential: MD
Phone: 301-529-4927