1750452694 NPI number — FAIRFAX FOOT AND ANKLE CENTER, P.C.

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 1750452694 NPI number — FAIRFAX FOOT AND ANKLE CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX FOOT AND ANKLE CENTER, 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:
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:
1750452694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10721 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-6914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-273-3622
Provider Business Mailing Address Fax Number:
703-273-0313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10721 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-6914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-273-3622
Provider Business Practice Location Address Fax Number:
703-273-0313
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLKIN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-273-3622

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103000250 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009303791 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8665 . This is a "CAREFIRST BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2153713 . This is a "AETNA HMO PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0604177 . This is a "CIGNA INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 346199PPO . This is a "NCPPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51277 . This is a "OP-CHOICE, MDIPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 207996 . This is a "ANTHEM BC BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4313936 . This is a "AETNA NON HMO PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51277 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".




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