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General NPI Number Information
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NPI Number | 1285749978
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Entity Type | Organization
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Legal Business Name | AVICENNA MEDICAL CLINIC, INC.
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Dates
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Enumeration Date | 08/20/2006
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Last Update Date | 11/03/2010
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Provider Practice Location Address
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Address Line | 50 S PICKETT STREET SUITE # 221
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City | ALEXANDRIA
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State | VA
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Zip | 22304-2922
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Country | US
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Telephone | 703-751-7331
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Fax | 703-751-2524
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Provider Business Mailing Address
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Address Line | 50 S PICKETT ST SUITE # 221
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City | ALEXANDRIA
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State | VA
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Zip | 22304-7207
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Country | US
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Telephone | 703-751-7331
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Fax | 703-751-2524
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Authorized Official
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Title or Position | PRINCIPAL
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Name | SATAR AHMADI
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Credential | M.D., M.P.H.
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Telephone | 703-751-7331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 0101041949
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License Number State | VA
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