Provider Demographics
NPI:1851515175
Name:THE PEDIATRIC GROUP, PC
Entity Type:Organization
Organization Name:THE PEDIATRIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-971-6900
Mailing Address - Street 1:7015 C MANCHESTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10527 BRADDOCK ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFAX,
Practice Address - State:VA
Practice Address - Zip Code:22032
Practice Address - Country:US
Practice Address - Phone:703-425-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Single Specialty