Provider Demographics
NPI:1811168081
Name:PEDIATRIC PARTNERS OF NORTHERN VIRGINIA
Entity type:Organization
Organization Name:PEDIATRIC PARTNERS OF NORTHERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-502-4500
Mailing Address - Street 1:4211 FAIRFAX CORNER EAST AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8622
Mailing Address - Country:US
Mailing Address - Phone:703-502-4500
Mailing Address - Fax:703-502-4518
Practice Address - Street 1:4211 FAIRFAX CORNER EAST AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8622
Practice Address - Country:US
Practice Address - Phone:703-502-4500
Practice Address - Fax:703-502-4518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty