Provider Demographics
NPI:1417142167
Name:TRICARE MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:TRICARE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-578-0707
Mailing Address - Street 1:5985 COLUMBIA PIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041
Mailing Address - Country:US
Mailing Address - Phone:703-578-0707
Mailing Address - Fax:703-578-0909
Practice Address - Street 1:5985 COLUMBIA PIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-2043
Practice Address - Country:US
Practice Address - Phone:703-578-0707
Practice Address - Fax:703-578-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010199620Medicaid
VA010199620Medicaid