Healthcare Provider Details

I. General information

NPI: 1467098137
Provider Name (Legal Business Name): RESTON MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR STE 212
RESTON VA
20190-3238
US

IV. Provider business mailing address

1800 TOWN CENTER DR STE 212
RESTON VA
20190-3238
US

V. Phone/Fax

Practice location:
  • Phone: 703-435-2227
  • Fax: 703-435-7856
Mailing address:
  • Phone: 703-435-2227
  • Fax: 703-435-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ELAINE FRATER
Title or Position: BILLING MANAGER
Credential:
Phone: 703-470-2907