Provider Demographics
NPI:1700887387
Name:THE CLINICAL SKIN CENTER OF NORTHERN VIRGINIA PLLC
Entity Type:Organization
Organization Name:THE CLINICAL SKIN CENTER OF NORTHERN VIRGINIA PLLC
Other - Org Name:CLINICAL SKIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STASHOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-620-8900
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-620-8900
Mailing Address - Fax:703-620-2288
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 404
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-620-8900
Practice Address - Fax:703-620-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00833Medicare ID - Type UnspecifiedMEDICARE GROUP #