=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366960593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHEVERLY PRIMARY CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6490 LANDOVER RD STE G
-----------------------------------------------------
City | CHEVERLY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-322-8000
-----------------------------------------------------
Fax | 301-322-1757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6490 LANDOVER RD STE G
-----------------------------------------------------
City | CHEVERLY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-322-8000
-----------------------------------------------------
Fax | 301-322-1757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHARON ANDERSON
-----------------------------------------------------
Credential | DNP, CRNP
-----------------------------------------------------
Telephone | 301-919-5316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | R135181
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------