Provider Demographics
NPI:1750870556
Name:EVERGREEN NEUROLOGY AND SLEEP CENTER
Entity type:Organization
Organization Name:EVERGREEN NEUROLOGY AND SLEEP CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ISHTIAQ
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-389-9712
Mailing Address - Street 1:8609 SUDLEY RD STE 204
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4500
Mailing Address - Country:US
Mailing Address - Phone:703-348-7207
Mailing Address - Fax:703-435-1844
Practice Address - Street 1:8609 SUDLEY RD STE 204
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4500
Practice Address - Country:US
Practice Address - Phone:703-348-7207
Practice Address - Fax:703-435-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012607532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty