Provider Demographics
NPI:1982010302
Name:VIRGINIA CARDIOVASCULAR GROUP, LLC
Entity Type:Organization
Organization Name:VIRGINIA CARDIOVASCULAR GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOU GHAZALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-939-9942
Mailing Address - Street 1:19450 DEERFIELD AVE
Mailing Address - Street 2:STE 335
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-6820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19450 DEERFIELD AVE
Practice Address - Street 2:STE 335
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6820
Practice Address - Country:US
Practice Address - Phone:703-939-9942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237500261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37073Medicare UPIN