Healthcare Provider Details

I. General information

NPI: 1003385709
Provider Name (Legal Business Name): CROWELL RECONSTRUCTIVE SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR STE 180
RESTON VA
20190-5905
US

IV. Provider business mailing address

1860 TOWN CENTER DR STE 180
RESTON VA
20190-5905
US

V. Phone/Fax

Practice location:
  • Phone: 571-525-2316
  • Fax: 571-313-0415
Mailing address:
  • Phone: 571-525-2316
  • Fax: 571-313-0415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PENNY MARSHALL
Title or Position: PATIENT ACCOUNTS
Credential:
Phone: 443-646-5001