Provider Demographics
NPI:1073564951
Name:OLD DOMINION ORTHOPAEDICS AND SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:OLD DOMINION ORTHOPAEDICS AND SPORTS MEDICINE, PC
Other - Org Name:NORTHERN VIRGINIA ORTHOPAEDIC SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-369-9070
Mailing Address - Street 1:8644 SUDLEY RD
Mailing Address - Street 2:STE. 308
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4425
Mailing Address - Country:US
Mailing Address - Phone:703-369-9070
Mailing Address - Fax:703-369-9240
Practice Address - Street 1:8644 SUDLEY RD
Practice Address - Street 2:STE 308
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4417
Practice Address - Country:US
Practice Address - Phone:703-369-9070
Practice Address - Fax:703-369-9240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK5164OtherRAILROAD MEDICARE
C06523Medicare UPIN
C06523Medicare ID - Type Unspecified