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NPI Code Detail

MEDICARE: MRS. SUSAN GAIL BAUM REGISTERED DIETITIAN

MEDICARE: MRS. SUSAN GAIL BAUM REGISTERED DIETITIAN
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
1133V00000XRegistered Dietitian

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14624075OTHERVAAETNA PROVIDER ID

General Provider Information

NPI Number : 1770621344
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SUSAN GAIL BAUM REGISTERED DIETITIAN
Provider Business Mailing Address
First Line : 15505 VINE COTTAGE DR
Second Line :
City : CENTREVILLE
State : VA
Zip : 20120-3750
Country : US
Telephone Number : 703-999-6290
Fax Number :
Provider Business Practice Location Address
First Line : 13135 LEE JACKSON MEMORIAL HWY
Second Line : STE 201
City : FAIRFAX
State : VA
Zip : 22033-1907
Country : US
Telephone Number : 703-999-6290
Fax Number : 703-241-7723
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/03/2007
Last Update Date : 08/09/2018

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Directions to “ MRS. SUSAN GAIL BAUM REGISTERED DIETITIAN” Practice Location

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