Provider Demographics
NPI:1659067122
Name:ADVANCED BRAIN CENTERS OF VA
Entity Type:Organization
Organization Name:ADVANCED BRAIN CENTERS OF VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEFINA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:571-201-8238
Mailing Address - Street 1:1860 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE G220
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:571-201-8238
Mailing Address - Fax:703-709-1119
Practice Address - Street 1:1860 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE G220
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:571-201-8238
Practice Address - Fax:703-709-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty