Provider Demographics
NPI:1285749978
Name:AVICENNA MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:AVICENNA MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:SATAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:703-751-7331
Mailing Address - Street 1:50 S PICKETT ST
Mailing Address - Street 2:SUITE # 221
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7207
Mailing Address - Country:US
Mailing Address - Phone:703-751-7331
Mailing Address - Fax:703-751-2524
Practice Address - Street 1:50 S PICKETT STREET
Practice Address - Street 2:SUITE # 221
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2922
Practice Address - Country:US
Practice Address - Phone:703-751-7331
Practice Address - Fax:703-751-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041949261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005623626Medicaid
VA005623626Medicaid
VA767039Medicare PIN