=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477844165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODBRIDGE ANESTHESIA GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2011
-----------------------------------------------------
Last Update Date | 04/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14904 JEFFERSON DAVIS HWY SUITE 103 & 104
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-497-4222
-----------------------------------------------------
Fax | 703-492-0164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14904 JEFFERSON DAVIS HWY SUITE 103 & 104
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-497-4222
-----------------------------------------------------
Fax | 703-492-0164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. MOHAMMAD HOSSEIN RAZAVI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-497-4222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------