Basic Information
| Provider Information | |||||||||
| NPI: | 1568560134 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GIANGERUSO | ||||||||
| FirstName: | ENRICO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224D CORNWALL ST NW STE 403 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376010 | ||||||||
| FaxNumber: | 5712919786 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 KENMORE AVENUE, SUITE 305 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037515763 | ||||||||
| FaxNumber: | 7033708704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | D0044362 | MD | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0102X | D0044362 | MD | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0006X | 0101258831 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 135291100 | 05 | MD | MEDICAID | 61489901 | 01 | MD | BLUE SHIELD | OTHER | W2270004 | 01 | DC | GHI | OTHER |