MEDICARE: YUILL BLACK MD AND MICHAEL R KLETZ MD PC

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	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CD8485	OTHER	VA	RAILROAD MEDICARE PIN

General Provider Information

NPI Number	:	1700802097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YUILL BLACK MD AND MICHAEL R KLETZ MD PC

Provider Business Mailing Address
First Line	:	1420 SPRING HILL RD
Second Line	:	SUITE 350
City	:	MCLEAN
State	:	VA
Zip	:	22102-3006
Country	:	US
Telephone Number	:	703-790-9722
Fax Number	:	703-893-8666

Provider Business Practice Location Address
First Line	:	1420 SPRING HILL RD
Second Line	:	SUITE 350
City	:	MCLEAN
State	:	VA
Zip	:	22102-3006
Country	:	US
Telephone Number	:	703-790-9722
Fax Number	:	703-893-8666

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MS. CHARLENE A DEVOL
Credential	:
Telephone Number	:	703-790-9675

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/31/2007

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