Basic Information
| Provider Information | |||||||||
| NPI: | 1841474020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEEHAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDONALD | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 309 RUCKER PL | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223012521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039221000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6501 LOISDALE CT | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221501826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039221000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2007 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101253473 | VA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | D0084668 | MD | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD045780 | DC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 062571 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.