Healthcare Provider Details

I. General information

NPI: 1912292400
Provider Name (Legal Business Name): EMILY SUSAN REARDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY REARDON PEROUTKA M.D.

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 AMHERST ST STE 300
WINCHESTER VA
22601-2917
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 320
WINCHESTER VA
22601-2889
US

V. Phone/Fax

Practice location:
  • Phone: 540-536-6721
  • Fax: 540-536-6724
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101272360
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: