Basic Information
Provider Information | |||||||||
NPI: | 1326088162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HULL | ||||||||
FirstName: | TOM | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2730-B PROSPERITY AVENUE | ||||||||
Address2: |   | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220312238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032891400 | ||||||||
FaxNumber: | 7032891414 | ||||||||
Practice Location | |||||||||
Address1: | 2300 OPITZ BLVD | ||||||||
Address2: |   | ||||||||
City: | WOODBRIDGE | ||||||||
State: | VA | ||||||||
PostalCode: | 221913311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032891400 | ||||||||
FaxNumber: | 7032891414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 0101041102 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
ID | Type | State | Issuer | Description | 6716091 | 05 | VA |   | MEDICAID | 6717748 | 05 | VA |   | MEDICAID | 6717730 | 05 | VA |   | MEDICAID | 3091113 | 01 |   | ECFMG | OTHER |