Provider Demographics
NPI:1174592745
Name:ANNANDALE PEDIATRIC ASSOC INC
Entity type:Organization
Organization Name:ANNANDALE PEDIATRIC ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-256-7200
Mailing Address - Street 1:7501 LITTLE RIVER TNPK
Mailing Address - Street 2:#202
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:703-256-7200
Mailing Address - Fax:703-658-0393
Practice Address - Street 1:7501 LITTLE RIVER TNPK
Practice Address - Street 2:#202
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003
Practice Address - Country:US
Practice Address - Phone:703-256-7200
Practice Address - Fax:703-658-0393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA41850208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F79459Medicare UPIN