Provider Demographics
NPI:1467475822
Name:GENERAL AND LAPAROSCOPIC SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:GENERAL AND LAPAROSCOPIC SURGICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEFANO
Authorized Official - Middle Name:FRANCO
Authorized Official - Last Name:AGOLINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-823-4066
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 419
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304
Mailing Address - Country:US
Mailing Address - Phone:703-823-4066
Mailing Address - Fax:703-823-4067
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 419
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-823-4066
Practice Address - Fax:703-823-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057385208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007504072Medicaid
DC49067Medicare ID - Type Unspecified
VA007504072Medicaid