Provider Demographics
NPI:1871842989
Name:PHENOM SURGICAL LLC
Entity Type:Organization
Organization Name:PHENOM SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:HEGENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSA
Authorized Official - Phone:703-659-4557
Mailing Address - Street 1:8116 ARLINGTON BLVD
Mailing Address - Street 2:#183
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1002
Mailing Address - Country:US
Mailing Address - Phone:703-659-4557
Mailing Address - Fax:703-205-2010
Practice Address - Street 1:2750 PROSPERITY AVE
Practice Address - Street 2:#120
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4312
Practice Address - Country:US
Practice Address - Phone:703-659-4557
Practice Address - Fax:703-205-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2906OtherNATIONAL SURGICAL ASSISTANT ASSOCIATION
DCSA0017OtherDEPARTMENT OF HEALTH, HEALTH PROFESSIONAL LICENSING ADMINISTRATION