Provider Demographics
NPI:1215334941
Name:BRANDON AVENUE PEDIATRICS
Entity type:Organization
Organization Name:BRANDON AVENUE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAAD O.
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-HARIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-830-6337
Mailing Address - Street 1:6126 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150
Mailing Address - Country:US
Mailing Address - Phone:571-830-6337
Mailing Address - Fax:
Practice Address - Street 1:6126 BRANDON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2610
Practice Address - Country:US
Practice Address - Phone:571-830-6337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty