Provider Demographics
NPI:1568706158
Name:BOULEVARD CENTER PEDIATRICS
Entity Type:Organization
Organization Name:BOULEVARD CENTER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-670-0300
Mailing Address - Street 1:3733 FETTLER PARK DR.
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025
Mailing Address - Country:US
Mailing Address - Phone:703-670-0300
Mailing Address - Fax:703-291-5331
Practice Address - Street 1:3733 FETTLER PARK DR.
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025
Practice Address - Country:US
Practice Address - Phone:703-670-0300
Practice Address - Fax:703-291-5331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244499208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty