=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578129599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METRO MOHS SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2019
-----------------------------------------------------
Last Update Date | 10/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 BACKLICK RD STE 120
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22151-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-966-7744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 BACKLICK RD STE 110&120
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22151-3933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-705-7505
-----------------------------------------------------
Fax | 866-990-3880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | KIMBERLY SELLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-705-7505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------