Healthcare Provider Details

I. General information

NPI: 1992137590
Provider Name (Legal Business Name): MAGNUS HEART AND VASCULAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 GENESEE PL SUITE 105
WOODBRIDGE VA
22192-8303
US

IV. Provider business mailing address

4004 GENESEE PL SUITE 105
WOODBRIDGE VA
22192-8303
US

V. Phone/Fax

Practice location:
  • Phone: 855-739-9953
  • Fax: 571-659-9445
Mailing address:
  • Phone: 855-739-9953
  • Fax: 571-659-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101242816
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number0101242816
License Number StateVA

VIII. Authorized Official

Name: DR. TSEDAY SIRAK
Title or Position: DIRECTOR
Credential: MD
Phone: 855-739-9953