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General NPI Number Information
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NPI Number | 1548634678
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICAL CENTER HOLDING LLC
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Dates
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Enumeration Date | 12/01/2015
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Last Update Date | 12/01/2015
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Provider Practice Location Address
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Address Line | 14904 JEFFERSON DAVIS HWY STE 205
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3908
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Country | US
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Telephone | 703-497-4500
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Fax | 703-494-4671
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Provider Business Mailing Address
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Address Line | 14904 JEFFERSON DAVIS HWY STE 205
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3908
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Country | US
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Telephone | 703-497-4500
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Fax | 703-494-4671
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Authorized Official
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Title or Position | MD/MEDICAL DIRECTOR
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Name | SALLU JABATI
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Credential |
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Telephone | 703-497-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101240114
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0101240114
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 0101240114
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License Number State | VA
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