Provider Demographics
NPI:1689769861
Name:NORTHERN VIRGINIA UROLOGY, PLLC
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA UROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTRAL BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYJO
Authorized Official - Middle Name:MAYBERRY
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:703-876-5942
Mailing Address - Street 1:10301 DEMOCRACY LN
Mailing Address - Street 2:SUITE 410
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2545
Mailing Address - Country:US
Mailing Address - Phone:703-876-5942
Mailing Address - Fax:703-876-5972
Practice Address - Street 1:10301 DEMOCRACY LN
Practice Address - Street 2:SUITE 410
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2545
Practice Address - Country:US
Practice Address - Phone:703-876-5942
Practice Address - Fax:703-876-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689769861Medicaid
1220932OtherAETNA HMO
N190OtherCAREFIRST BCBS
7845793OtherAETNA PPO
7845793OtherAETNA PPO
VA1689769861Medicaid