Provider Demographics
NPI:1922162205
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:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRADER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:703-971-6900
Mailing Address - Street 1:7015C MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3253
Mailing Address - Country:US
Mailing Address - Phone:703-971-6900
Mailing Address - Fax:703-971-9184
Practice Address - Street 1:7015C MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3253
Practice Address - Country:US
Practice Address - Phone:703-971-6900
Practice Address - Fax:703-971-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty