Provider Demographics
NPI:1285998955
Name:GARY J. SOVEROW, MD, PC
Entity type:Organization
Organization Name:GARY J. SOVEROW, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:SOVEROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-821-1324
Mailing Address - Street 1:6888 ELM ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3894
Mailing Address - Country:US
Mailing Address - Phone:703-821-1324
Mailing Address - Fax:703-821-1324
Practice Address - Street 1:6888 ELM ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3894
Practice Address - Country:US
Practice Address - Phone:703-821-1324
Practice Address - Fax:703-821-1324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARY J. SOVEROW, MD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010290672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPTAN 145572Medicare PIN