Basic Information
| Provider Information | |||||||||
| NPI: | 1891742789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEFALE | ||||||||
| FirstName: | GEORGIS | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| 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: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 0101041109 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6716334 | 05 | VA | MEDICAID | 6718809 | 05 | VA | MEDICAID | 6717560 | 05 | VA | MEDICAID | 2142032 | 01 | ECFMG | OTHER |