Provider Demographics
NPI:1689965865
Name:PRINCE WILLIAM PEDIATRICS AND ADOLESCENT CENTER
Entity Type:Organization
Organization Name:PRINCE WILLIAM PEDIATRICS AND ADOLESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:JADIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-492-1400
Mailing Address - Street 1:12722 DIRECTORS LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2462
Mailing Address - Country:US
Mailing Address - Phone:703-492-1400
Mailing Address - Fax:703-492-0220
Practice Address - Street 1:12722 DIRECTORS LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2462
Practice Address - Country:US
Practice Address - Phone:703-492-1400
Practice Address - Fax:703-492-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230761261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154567352Medicaid
VA1013010180Medicaid