Provider Demographics
NPI:1629496088
Name:BOSTON MEDICAL GROUP- VIRGINIA, P.C.
Entity Type:Organization
Organization Name:BOSTON MEDICAL GROUP- VIRGINIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-808-2828
Mailing Address - Street 1:4216 KING STREET
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302
Mailing Address - Country:US
Mailing Address - Phone:703-845-7411
Mailing Address - Fax:703-845-7409
Practice Address - Street 1:4216 KING STREET
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302
Practice Address - Country:US
Practice Address - Phone:703-845-7411
Practice Address - Fax:703-845-7409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty