Provider Demographics
NPI:1366748634
Name:NORTHERN VIRGINIA GASTROENTEROLOGY, PC
Entity type:Organization
Organization Name:NORTHERN VIRGINIA GASTROENTEROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LASNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-263-3393
Mailing Address - Street 1:6211 CENTREVILLE ROAD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2635
Mailing Address - Country:US
Mailing Address - Phone:703-263-3393
Mailing Address - Fax:703-263-2606
Practice Address - Street 1:6211 CENTREVILLE ROAD
Practice Address - Street 2:SUITE 500
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2635
Practice Address - Country:US
Practice Address - Phone:703-263-3393
Practice Address - Fax:703-263-2606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA001014OtherMEDICARE MIN