Provider Demographics
NPI:1053638809
Name:JANET AVERY MD PLC
Entity Type:Organization
Organization Name:JANET AVERY MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:KETKESONE
Authorized Official - Middle Name:
Authorized Official - Last Name:NANTHAVONGSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-986-7175
Mailing Address - Street 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-481-5907
Mailing Address - Fax:703-435-0660
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 310
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-481-5907
Practice Address - Fax:703-435-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA506305Medicare UPIN