Healthcare Provider Details

I. General information

NPI: 1366114167
Provider Name (Legal Business Name): NORTHERN VIRGINIA MULTI-SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR STE 350
RESTON VA
20190-5912
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4692
US

V. Phone/Fax

Practice location:
  • Phone: 703-224-9999
  • Fax: 571-384-6702
Mailing address:
  • Phone: 615-376-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM TEDERICK JOHNSON
Title or Position: GROUP VP/AO
Credential:
Phone: 615-372-3375