1356943278 NPI number — FAIRFAX RADIOLOGY BREAST CENTER OF LOUDOUN

Table of content: (NPI 1356943278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356943278 NPI number — FAIRFAX RADIOLOGY BREAST CENTER OF LOUDOUN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX RADIOLOGY BREAST CENTER OF LOUDOUN
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:
1356943278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2722 MERRILEE DR STE 230
Provider Second Line Business Mailing Address:
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:
703-698-4444
Provider Business Mailing Address Fax Number:
703-698-2176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19465 DEERFIELD AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSDOWNE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-788-8426
Provider Business Practice Location Address Fax Number:
571-382-6587
Provider Enumeration Date:
11/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MASTERS
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
703-698-4444

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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