=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740550201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMAL PREVENTIVE MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2011
-----------------------------------------------------
Last Update Date | 03/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2112 F STREET, NW SUITE 501
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-296-1438
-----------------------------------------------------
Fax | 202-296-1549
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2112 F STREET, NW SUITE 501
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-296-1438
-----------------------------------------------------
Fax | 202-296-1549
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SYLVIA RENEE MEDLEY
-----------------------------------------------------
Credential | M.D., M.P.H
-----------------------------------------------------
Telephone | 202-296-1438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0901X
-----------------------------------------------------
Taxonomy Name | Public Health & General Preventive Medicine Physician
-----------------------------------------------------
License Number | MD304445
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD304445
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------