Provider Demographics
NPI:1215091038
Name:ELDEN ST. PEDIATRICS
Entity type:Organization
Organization Name:ELDEN ST. PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN.OFC.MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:TETTEYFIO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:703-471-6996
Mailing Address - Street 1:110 ELDEN ST
Mailing Address - Street 2:SUITE #D
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4891
Mailing Address - Country:US
Mailing Address - Phone:703-471-6996
Mailing Address - Fax:703-435-7765
Practice Address - Street 1:110 ELDEN ST
Practice Address - Street 2:SUITE #D
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4891
Practice Address - Country:US
Practice Address - Phone:703-471-6996
Practice Address - Fax:703-435-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty