Provider Demographics
NPI:1043226731
Name:PLASTIC SURGERY ASSOCIATES OF NORTHERN VIRGINIA, LTD
Entity Type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF NORTHERN VIRGINIA, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FREEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-525-2316
Mailing Address - Street 1:1860 TOWN CENTER DR STE 180
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5905
Mailing Address - Country:US
Mailing Address - Phone:571-525-2316
Mailing Address - Fax:571-313-0415
Practice Address - Street 1:1860 TOWN CENTER DR STE 180
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5905
Practice Address - Country:US
Practice Address - Phone:571-525-2316
Practice Address - Fax:571-313-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043977208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C98506Medicare UPIN
561047B21Medicare ID - Type Unspecified