Provider Demographics
NPI:1659405843
Name:MY FAMILY DOCTOR
Entity Type:Organization
Organization Name:MY FAMILY DOCTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:703-573-7200
Mailing Address - Street 1:722 GRANT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-573-7200
Mailing Address - Fax:703-547-0724
Practice Address - Street 1:722 GRANT ST
Practice Address - Street 2:SUITE A
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:703-573-7200
Practice Address - Fax:703-547-0724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056112174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02550Medicare PIN