Provider Demographics
NPI:1013335371
Name:BRADLEE FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:BRADLEE FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GONDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-379-6020
Mailing Address - Street 1:3541 W BRADDOCK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1915
Mailing Address - Country:US
Mailing Address - Phone:703-379-6020
Mailing Address - Fax:703-820-8799
Practice Address - Street 1:3541 W BRADDOCK RD
Practice Address - Street 2:101
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1915
Practice Address - Country:US
Practice Address - Phone:703-379-6020
Practice Address - Fax:703-820-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101223709261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2466957OtherUNITED HEALTH CARE
4718781OtherCIGNA
3681092OtherAETNA HMO
7782527OtherAETNA PPO
VA283569OtherINTOTAL
172715OtherANTHEM HEALTHKEEPERS
VA5613060Medicaid
DCK2040001OtherBCBS
VA5613060Medicaid