Basic Information
Provider Information | |||||||||
NPI: | 1932315272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEREEF | ||||||||
FirstName: | SERENE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | WINCHESTER | ||||||||
State: | VA | ||||||||
PostalCode: | 226012896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5405365100 | ||||||||
FaxNumber: | 5405360235 | ||||||||
Practice Location | |||||||||
Address1: | 190 CAMPUS BLVD STE 310 | ||||||||
Address2: |   | ||||||||
City: | WINCHESTER | ||||||||
State: | VA | ||||||||
PostalCode: | 226012872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5405360130 | ||||||||
FaxNumber: | 5405360140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | P3585 | TX | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 0101272242 | VA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 01074924A | IN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000000925834 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 201275680 | 05 | IN |   | MEDICAID |