Provider Demographics
NPI:1861616310
Name:ANNANDALE MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:ANNANDALE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:INSOOK
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-378-3508
Mailing Address - Street 1:PO BOX 9302
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-0302
Mailing Address - Country:US
Mailing Address - Phone:703-378-3508
Mailing Address - Fax:703-378-6414
Practice Address - Street 1:4229 LAFAYETTE CENTER DRIVE
Practice Address - Street 2:SUITE #1790
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1267
Practice Address - Country:US
Practice Address - Phone:703-378-3508
Practice Address - Fax:703-378-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3100539OtherALLANCE PPO/MAMSI
VA463068OtherBCBS-ANTHEM
VA38080001OtherBCBS-CAREFIRST
VA461868OtherAETNA
VA136631OtherPTAN
VA4528765OtherAETNA
VACH752738Medicare PIN
VA463068OtherBCBS-ANTHEM