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General NPI Number Information
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NPI Number | 1124239470
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Entity Type | Organization
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Legal Business Name | GENERATIONS FAMILY MEDICINE PC
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Dates
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Enumeration Date | 05/25/2007
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Last Update Date | 01/04/2013
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Provider Practice Location Address
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Address Line | 12040 S LAKES DR STE 190
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City | RESTON
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State | VA
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Zip | 20191-1246
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Country | US
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Telephone | 703-464-0686
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Fax | 703-464-0698
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Provider Business Mailing Address
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Address Line | 12040 S LAKES DR SUITE 207
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City | RESTON
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State | VA
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Zip | 20191-1246
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Country | US
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Telephone | 703-464-0686
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Fax | 703-464-0698
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. KEVIN JOHN KELLEHER
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Credential | MD
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Telephone | 703-464-0686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101054571
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License Number State | VA
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