Healthcare Provider Details

I. General information

NPI: 1447245279
Provider Name (Legal Business Name): FAIRFAX MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PARK ST S
FAIRFAX MN
55332-3153
US

IV. Provider business mailing address

PO BOX 529 300 SOUTH PARK ST
FAIRFAX MN
55332-0529
US

V. Phone/Fax

Practice location:
  • Phone: 507-426-7228
  • Fax: 507-426-8257
Mailing address:
  • Phone: 507-426-7228
  • Fax: 507-426-8257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS FREDERICK GILLES
Title or Position: PHYSICIAN
Credential: MD
Phone: 507-426-7228