Provider Demographics
NPI:1073544656
Name:BLUE NILE MEDICAL CENTER PC
Entity Type:Organization
Organization Name:BLUE NILE MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TEDLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANBESSIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-845-0700
Mailing Address - Street 1:85 S BRAGG ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-2797
Mailing Address - Country:US
Mailing Address - Phone:703-845-0700
Mailing Address - Fax:703-794-2269
Practice Address - Street 1:85 S BRAGG ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-2797
Practice Address - Country:US
Practice Address - Phone:703-845-0700
Practice Address - Fax:703-794-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01742Medicare PIN
C09674Medicare PIN