Provider Demographics
NPI:1093024010
Name:NORTHERN VIRGINIA GASTROENTEROLOGY AND HEPATOLOGY
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA GASTROENTEROLOGY AND HEPATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLO PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIRA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:ALI IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-613-6351
Mailing Address - Street 1:10102 E LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2732
Mailing Address - Country:US
Mailing Address - Phone:301-613-6351
Mailing Address - Fax:
Practice Address - Street 1:5254 DAWES AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1404
Practice Address - Country:US
Practice Address - Phone:301-613-6351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-26
Last Update Date:2010-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244137174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty