=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841497583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROLOGICAL INSTITUTE OF NORTHERN VIRGINIA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 01/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5130 DUKE ST SUITE 9
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-370-9411
-----------------------------------------------------
Fax | 703-370-9417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5130 DUKE ST SUITE 9
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-370-9411
-----------------------------------------------------
Fax | 703-370-9417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HAIDEH YAZDANI SABET
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-370-9411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101235251
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------