Provider Demographics
NPI:1649448093
Name:MANCHESTER LAKES MEDICAL
Entity type:Organization
Organization Name:MANCHESTER LAKES MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-483-7706
Mailing Address - Street 1:422 GARRISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1573
Mailing Address - Country:US
Mailing Address - Phone:540-658-9340
Mailing Address - Fax:
Practice Address - Street 1:7015 E MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310
Practice Address - Country:US
Practice Address - Phone:757-483-7706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00558Medicare PIN
G00558Medicare Oscar/Certification
E66437Medicare UPIN