Provider Demographics
NPI:1912078619
Name:CLIFTON CENTREVILLE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:CLIFTON CENTREVILLE MEDICAL ASSOCIATES
Other - Org Name:CCMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEVINSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-802-2004
Mailing Address - Street 1:5895 TRINITY PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1996
Mailing Address - Country:US
Mailing Address - Phone:703-802-2004
Mailing Address - Fax:703-802-2113
Practice Address - Street 1:5895 TRINITY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-1995
Practice Address - Country:US
Practice Address - Phone:703-802-2004
Practice Address - Fax:703-802-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237688207Q00000X
VA0101-049277207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006078508Medicaid
VAVV1662BOtherMEDICARE GBA
VA006078508Medicaid
VA191304C61Medicare PIN
VAH67976Medicare UPIN
VAC08418Medicare PIN
VACJ2257Medicare PIN
VAVV1662BOtherMEDICARE GBA
VAJ2257Medicare PIN
VA191304YW1Medicare UPIN
VA739642C61Medicare PIN