Provider Demographics
NPI:1114109261
Name:DOMINION MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:DOMINION MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-870-3540
Mailing Address - Street 1:11463 RIDGE RD
Mailing Address - Street 2:P.O. BOX 999
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-4078
Mailing Address - Country:US
Mailing Address - Phone:301-870-3540
Mailing Address - Fax:301-392-1726
Practice Address - Street 1:11463 RIDGE RD
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-4078
Practice Address - Country:US
Practice Address - Phone:301-870-3540
Practice Address - Fax:301-392-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05561Medicare PIN