MEDICARE: MILLENNIUM MEDICAL CENTER LLC

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	207R00000X	Internal Medicine Physician	0101242652	VA

General Provider Information

NPI Number	:	1689909897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3606 FOREST DR
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-1005
Country	:	US
Telephone Number	:	703-820-7520
Fax Number	:

Provider Business Practice Location Address
First Line	:	3606 FOREST DR
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-1005
Country	:	US
Telephone Number	:	703-820-7520
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHAYMA AL-MUDHAFAR
Credential	:	MD
Telephone Number	:	703-820-7520

Provider Enumeration Date	:	10/06/2009
Last Update Date	:	10/06/2009

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