=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164858205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEL MEDICAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2013
-----------------------------------------------------
Last Update Date | 09/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14904 JEFFERSON DAVIS HWY SUITE 205
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-497-4500
-----------------------------------------------------
Fax | 703-494-4671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14904 JEFFERSON DAVIS HWY SUITE 205
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-497-4500
-----------------------------------------------------
Fax | 703-494-4671
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHRIHARSH LAXMAN POLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-497-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 0024166397
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------