1689850554 NPI number — FAIRFAX RADIOLOGICAL CONSULTANTS PC

Table of content: (NPI 1689850554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689850554 NPI number — FAIRFAX RADIOLOGICAL CONSULTANTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX RADIOLOGICAL CONSULTANTS 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:
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:
1689850554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2722 MERRILEE DR
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-698-4483
Provider Business Mailing Address Fax Number:
703-573-0880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3299 WOODBURN RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
ANNANDALE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22003-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-698-4483
Provider Business Practice Location Address Fax Number:
703-573-0880
Provider Enumeration Date:
01/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ALLISON
Authorized Official First Name:
BILL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
703-698-4483

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 033140 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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