MEDICARE: THE PHYSICIAN AND MIDWIFE COLLABORATIVE PRACTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	0101026374	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G00252	OTHER	VA	MEDICARE

General Provider Information

NPI Number	:	1073799839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PHYSICIAN AND MIDWIFE COLLABORATIVE PRACTICE

Provider Business Mailing Address
First Line	:	4660 KENMORE AVE
Second Line	:	SUITE 902
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1313
Country	:	US
Telephone Number	:	703-370-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 KINGSTOWNE VILLAGE PKWY
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22315-5880
Country	:	US
Telephone Number	:	703-922-3434
Fax Number	:	703-922-6588

Authorized Official
Title or Position	:	CEO
Name	:	DR. DAVID GIAMMITTORIO
Credential	:	M.D.
Telephone Number	:	703-370-4300

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/11/2008

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Directions to “THE PHYSICIAN AND MIDWIFE COLLABORATIVE PRACTICE ” Practice Location

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