Provider Demographics
NPI:1750462735
Name:SHILOH FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:SHILOH FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-823-3660
Mailing Address - Street 1:5249 DUKE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2926
Mailing Address - Country:US
Mailing Address - Phone:703-823-3660
Mailing Address - Fax:703-823-2210
Practice Address - Street 1:5249 DUKE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2926
Practice Address - Country:US
Practice Address - Phone:703-823-3660
Practice Address - Fax:703-823-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050807305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC72887Medicare UPIN