Healthcare Provider Details

I. General information

NPI: 1548358831
Provider Name (Legal Business Name): THE GASTROENTEROLOGY GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 ROLAND CLARKE PL STE 200
RESTON VA
20191-1445
US

IV. Provider business mailing address

1939 ROLAND CLARKE PL STE 200
RESTON VA
20191-1445
US

V. Phone/Fax

Practice location:
  • Phone: 703-435-3366
  • Fax: 703-782-8833
Mailing address:
  • Phone: 703-435-3366
  • Fax: 703-782-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA DARLENE GLENN
Title or Position: OFFICE MANAGER
Credential:
Phone: 703-766-2650