Provider Demographics
NPI:1972832608
Name:PENDERBROOK INTERNAL MEDICINE AND WELLNESS, PLLC
Entity type:Organization
Organization Name:PENDERBROOK INTERNAL MEDICINE AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THIEN QUANG
Authorized Official - Middle Name:DAT
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-716-5404
Mailing Address - Street 1:4001 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2917
Mailing Address - Country:US
Mailing Address - Phone:703-716-5404
Mailing Address - Fax:703-716-5410
Practice Address - Street 1:4001 FAIR RIDGE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-716-5404
Practice Address - Fax:703-716-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101840408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty