Provider Demographics
NPI:1932199676
Name:HAILE, LYDIA (PA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:HAILE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20010 CENTURY BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1115
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:240-686-2330
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:ALEXANDRIA HOSPITAL
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3066
Practice Address - Fax:703-504-3866
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231495207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005803403Medicaid
VA007660E14Medicare ID - Type Unspecified
MD007660E14Medicare ID - Type Unspecified
VA005803403Medicaid