1710060330 NPI number — FAIRFAX FAMILY PRACTICE CENTERS, P.C.

Table of content: (NPI 1710060330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710060330 NPI number — FAIRFAX FAMILY PRACTICE CENTERS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX FAMILY PRACTICE CENTERS, P.C.
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:
FAMILY MEDICINE OF CLIFTON-CENTREVILLE
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:
1710060330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2014
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:
703-391-2030
Provider Business Mailing Address Fax Number:
703-273-3943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 CENTREVILLE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTREVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20121-2626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-263-9600
Provider Business Practice Location Address Fax Number:
703-266-1452
Provider Enumeration Date:
10/24/2006

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:
703-391-2030

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: 0631926 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1548266117 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1699771394 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5618916 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CO8267 . This is a "VIRGINIA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: G00522 . This is a "MEDICARE HIGHMARK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1487657136 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010072409 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790781474 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5618959 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1205944964 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1245236926 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5604761 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5619181 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11664428801 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5619050 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5619076 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063418762 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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