=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548339682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA PATHOLOGY SVCS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6121 LINCOLNIA RD SUITE 108
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-256-2962
-----------------------------------------------------
Fax | 703-256-3608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6121 LINCOLNIA RD SUITE 108
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-256-2962
-----------------------------------------------------
Fax | 703-256-3608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR PRESIDENT
-----------------------------------------------------
Name | DR. MARY GREISS ROUSHDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-256-2962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number | 0101033048
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------