Provider Demographics
NPI:1619290582
Name:PRIMA MEDICINE
Entity Type:Organization
Organization Name:PRIMA MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHETHANA
Authorized Official - Middle Name:V
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-870-3750
Mailing Address - Street 1:3903 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 218
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2943
Mailing Address - Country:US
Mailing Address - Phone:703-870-3750
Mailing Address - Fax:703-594-8604
Practice Address - Street 1:3903 FAIR RIDGE DR
Practice Address - Street 2:SUITE 218
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2943
Practice Address - Country:US
Practice Address - Phone:703-870-3750
Practice Address - Fax:703-594-8604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty