Provider Demographics
NPI:1457445413
Name:HERITAGE VILLAGE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:HERITAGE VILLAGE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCISCIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-753-2922
Mailing Address - Street 1:7110 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3075
Mailing Address - Country:US
Mailing Address - Phone:703-753-2922
Mailing Address - Fax:703-753-4383
Practice Address - Street 1:7110 HERITAGE VILLAGE PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3075
Practice Address - Country:US
Practice Address - Phone:703-753-2922
Practice Address - Fax:703-753-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09685Medicare UPIN
VAI07054Medicare UPIN