Provider Demographics
NPI:1649215955
Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity type:Organization
Organization Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMINISTRTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-436-1200
Mailing Address - Street 1:1500 N BEAUREGARD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1700
Mailing Address - Country:US
Mailing Address - Phone:703-436-1200
Mailing Address - Fax:703-499-9670
Practice Address - Street 1:1500 N BEAUREGARD ST STE 200
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1700
Practice Address - Country:US
Practice Address - Phone:703-436-1200
Practice Address - Fax:703-499-9670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101038289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6721001Medicaid
VA6719694Medicaid
VA6733816Medicaid
VA6792896Medicaid
VA6738214Medicaid
VA6704999Medicaid
VA010077036Medicaid
VA6738206Medicaid
VA6737935Medicaid
VA6721001Medicaid
VA6738206Medicaid
VAF76852Medicare UPIN
VA6733816Medicaid