1104003060 NPI number — FAIRFAX RADIOLOGICAL CONSULTANTS PC

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 1104003060 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:
1104003060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
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:
8318 ARLINGTON BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22031-5218
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:
01/23/2008

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: "Y" .

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

  • Identifier: 089072 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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