Provider Demographics
NPI:1689629255
Name:PROFESSIONAL HEALTHCARE GROUP
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:FLEMING
Authorized Official - Last Name:MCCLATCHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-580-7192
Mailing Address - Street 1:PO BOX 6400
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22195-6400
Mailing Address - Country:US
Mailing Address - Phone:703-490-8106
Mailing Address - Fax:703-580-7183
Practice Address - Street 1:5504 STAPLES MILL PLZ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-3247
Practice Address - Country:US
Practice Address - Phone:703-580-7192
Practice Address - Fax:703-580-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D1010340291U00000X
VA0206009192332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010280907Medicaid
VA010303524Medicaid
VA010303524Medicaid
VA4529730001Medicare ID - Type UnspecifiedMEDICAL SUPPLIES & EQUIPM