Healthcare Provider Details

I. General information

NPI: 1740235266
Provider Name (Legal Business Name): ANDREW BASLER DAHLGREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 MEADOWBRIDGE RD SUITE 200
MECHANICSVILLE VA
23116-2331
US

IV. Provider business mailing address

1115 BOULDERS PKWY SUITE 200
NORTH CHESTERFIELD VA
23225-4067
US

V. Phone/Fax

Practice location:
  • Phone: 804-730-2121
  • Fax: 804-730-0563
Mailing address:
  • Phone: 804-560-5595
  • Fax: 804-560-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number4301074317
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101057080
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057080
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: