Basic Information
| Provider Information | |||||||||
| NPI: | 1003802208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SENECA | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 FAIR RIDGE DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 FAIR RIDGE DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101019015 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7379056 | 05 | VA | MEDICAID |