Healthcare Provider Details

I. General information

NPI: 1578828505
Provider Name (Legal Business Name): TYSONS GYNECOLOGY AND MENOPAUSE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8320 OLD COURTHOUSE RD 400
VIENNA VA
22182-3831
US

IV. Provider business mailing address

8320 OLD COURTHOUSE RD 400
VIENNA VA
22182-3831
US

V. Phone/Fax

Practice location:
  • Phone: 703-226-4012
  • Fax: 703-226-4010
Mailing address:
  • Phone: 703-226-4012
  • Fax: 703-226-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0101035022
License Number StateVA

VIII. Authorized Official

Name: MELINDA S HALL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 703-226-4012