MEDICARE: CHISOVEREIGN PLLC

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	261QM2500X	Medical Specialty Clinic/Center	0101246435	VA

General Provider Information

NPI Number	:	1225454291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHISOVEREIGN PLLC

Provider Business Mailing Address
First Line	:	3975 FAIR RIDGE DR
Second Line	:	SUITE 150N
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2911
Country	:	US
Telephone Number	:	703-246-0011
Fax Number	:	703-246-0012

Provider Business Practice Location Address
First Line	:	3975 FAIR RIDGE DR
Second Line	:	SUITE 150N
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2911
Country	:	US
Telephone Number	:	703-246-0011
Fax Number	:	703-246-0012

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. IJEOMA N NNAMANI
Credential	:	MD, PHD
Telephone Number	:	703-505-2476

Provider Enumeration Date	:	03/13/2014
Last Update Date	:	03/13/2014

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