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

Table of content: (NPI 1750452694)

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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