Healthcare Provider Details

I. General information

NPI: 1528438884
Provider Name (Legal Business Name): MCLEAN AMBULATORY SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 LEWINSVILLE RD SUITE 440
MC LEAN VA
22102-2814
US

IV. Provider business mailing address

7601 LEWINSVILLE RD SUITE 440
MCLEAN VA
22102-2834
US

V. Phone/Fax

Practice location:
  • Phone: 703-663-1440
  • Fax: 703-752-1105
Mailing address:
  • Phone: 703-663-1440
  • Fax: 703-752-1105

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: DARASINH PHOUMMITHONE MAYARD
Title or Position: A/R & OPERATIONS MANAGER
Credential: AUTHORIZED OFFICIAL
Phone: 703-395-6410