Provider Demographics
NPI:1124004296
Name:COUNTRYSIDE ORTHOPAEDICS PC
Entity Type:Organization
Organization Name:COUNTRYSIDE ORTHOPAEDICS PC
Other - Org Name:COUNTRYSIDE ORTHOPAEDICPHYSICAL THERAPY AND HAND REHABILITATION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:F
Authorized Official - Last Name:LOWER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-858-1800
Mailing Address - Street 1:19465 DEERFIELD AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1707
Mailing Address - Country:US
Mailing Address - Phone:703-858-1800
Mailing Address - Fax:703-858-1801
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1707
Practice Address - Country:US
Practice Address - Phone:703-858-1800
Practice Address - Fax:703-858-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherEIN
VA0957850001Medicare NSC
VAG01767Medicare PIN
VAC04438Medicare PIN