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General NPI Number Information
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NPI Number | 1326243395
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Entity Type | Organization
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Legal Business Name | ADULT PRIMARY CARE CENTER LLC
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Dates
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Enumeration Date | 06/19/2007
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Last Update Date | 11/08/2007
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Provider Practice Location Address
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Address Line | 2200 OPITZ BLVD SUITE 350
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3321
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Country | US
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Telephone | 845-426-6864
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 OPITZ BLVD SUITE 350
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3321
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Country | US
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Telephone | 845-426-6864
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SIAMAK HEYDARIAN
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Credential | MD
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Telephone | 845-426-6864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0101048248
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License Number State | VA
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