1447245279 NPI number — FAIRFAX MEDICAL CLINIC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447245279 NPI number — FAIRFAX MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX MEDICAL CLINIC PA
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:
Provider Other Organization Name Type Code:
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:
1447245279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 529
Provider Second Line Business Mailing Address:
300 SOUTH PARK ST
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55332-0529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-426-7228
Provider Business Mailing Address Fax Number:
507-426-8257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PARK ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55332-3153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-426-7228
Provider Business Practice Location Address Fax Number:
507-426-8257
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GILLES
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
FREDERICK
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
507-426-7228

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)

  • Identifier: 0105551 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 109697 . This is a "U-CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1013965 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 47164GI . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP21655 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 773742 . This is a "WORLD INS" identifier . This identifiers is of the category "OTHER".




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