Provider Demographics
NPI:1841494796
Name:PEDIATRIC PHYSICIANS OF RESTON, PC
Entity type:Organization
Organization Name:PEDIATRIC PHYSICIANS OF RESTON, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RT R
Authorized Official - Phone:703-435-0325
Mailing Address - Street 1:1830 TOWN CENTER DR
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3292
Mailing Address - Country:US
Mailing Address - Phone:703-435-3636
Mailing Address - Fax:703-435-9145
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE # 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3292
Practice Address - Country:US
Practice Address - Phone:703-435-3636
Practice Address - Fax:703-435-9145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty