Healthcare Provider Details

I. General information

NPI: 1417045816
Provider Name (Legal Business Name): FAMILY MEDICINE OF LAKE RIDGE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 COMMISSION CT STE 201
WOODBRIDGE VA
22192
US

IV. Provider business mailing address

3401 COMMISSION CT STE 201
WOODBRIDGE VA
22192
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-6265
  • Fax: 703-490-6713
Mailing address:
  • Phone: 703-490-6265
  • Fax: 703-490-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101039027
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0024057411
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101040586
License Number StateVA

VIII. Authorized Official

Name: DR. GERRY A COPE
Title or Position: PHYSICIAN
Credential: MD
Phone: 703-490-6265