MEDICARE: MOUNT VERNON INTERNAL MEDICINE

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	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	198871	OTHER	VA	MEDICARE PTAN

General Provider Information

NPI Number	:	1205135183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT VERNON INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	6128 BRANDON AVE
Second Line	:	SUITE 205
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-2640
Country	:	US
Telephone Number	:	703-780-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6128 BRANDON AVE
Second Line	:	SUITE 205
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-2640
Country	:	US
Telephone Number	:	703-780-2800
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALBERT HERRERA
Credential	:	M.D.
Telephone Number	:	703-780-2800

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	03/18/2011

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