Provider Demographics
NPI:1417045816
Name:FAMILY MEDICINE OF LAKE RIDGE PC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF LAKE RIDGE PC
Other - Org Name:FAMILY MEDICINE OF LAKE RIDGE
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-490-6265
Mailing Address - Street 1:3401 COMMISSION CT
Mailing Address - Street 2:STE 201
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-490-6265
Mailing Address - Fax:703-490-6713
Practice Address - Street 1:3401 COMMISSION CT
Practice Address - Street 2:STE 201
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-490-6265
Practice Address - Fax:703-490-6713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040586207Q00000X
VA0101039027207Q00000X
VA0024057411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04904Medicare ID - Type Unspecified