1588788764 NPI number — FAIRFAX FAMILY PRACTICE CENTERS PC

Table of content: (NPI 1588788764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588788764 NPI number — FAIRFAX FAMILY PRACTICE CENTERS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX FAMILY PRACTICE CENTERS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRINCE WILLIAM FAMILY MEDICINE GAINESVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588788764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 791128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21279-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-257-8090
Provider Business Mailing Address Fax Number:
703-257-7822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8078 CRESCENT PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-257-8090
Provider Business Practice Location Address Fax Number:
703-257-7822
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-255-9100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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