Healthcare Provider Details

I. General information

NPI: 1598297269
Provider Name (Legal Business Name): CCRM NORTHERN VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8010 TOWERS CRESCENT DR 5TH FLOOR
VIENNA VA
22182-2710
US

IV. Provider business mailing address

8010 TOWERS CRESCENT DR FL 5
VIENNA VA
22182-2710
US

V. Phone/Fax

Practice location:
  • Phone: 571-789-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATT TYSON
Title or Position: DIRECTOR, MANAGED CARE CONTRACTING
Credential:
Phone: 615-477-6677