MEDICARE: LESLIE R PICKENS M.D.

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	207P00000X	Emergency Medicine Physician	0101046241	VA

General Provider Information

NPI Number	:	1871677799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE R PICKENS M.D.

Provider Business Mailing Address
First Line	:	8804 SURREY CT
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22309-2243
Country	:	US
Telephone Number	:	703-329-1037
Fax Number	:	703-329-4595

Provider Business Practice Location Address
First Line	:	6020 RICHMOND HWY STE 100
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22303-2157
Country	:	US
Telephone Number	:	703-329-1037
Fax Number	:	703-329-4595

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	05/24/2012

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