Provider Demographics
NPI:1417053794
Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity Type:Organization
Organization Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Other - Org Name:LAKE RIDGE OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-212-6600
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-212-6600
Mailing Address - Fax:703-931-0961
Practice Address - Street 1:1990 OLD BRIDGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2383
Practice Address - Country:US
Practice Address - Phone:703-212-6600
Practice Address - Fax:703-931-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty