Provider Demographics
NPI:1063442077
Name:INOVA LOUDOUN AMBULATORY SURGERY
Entity type:Organization
Organization Name:INOVA LOUDOUN AMBULATORY SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROYBAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-209-6465
Mailing Address - Street 1:44035 RIVERSIDE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8260
Mailing Address - Country:US
Mailing Address - Phone:571-209-6465
Mailing Address - Fax:571-209-6478
Practice Address - Street 1:44035 RIVERSIDE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8260
Practice Address - Country:US
Practice Address - Phone:571-209-6465
Practice Address - Fax:571-209-6478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH700261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192949769Medicare PIN