Healthcare Provider Details

I. General information

NPI: 1538362504
Provider Name (Legal Business Name): FAIRFAX NEONATAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PROSPERITY AVE STE A
FAIRFAX VA
22031-4330
US

IV. Provider business mailing address

2730 PROSPERITY AVE # B
FAIRFAX VA
22031-4329
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-1410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN HALTERMAN
Title or Position: PROJECT MANAGER
Credential:
Phone: 703-289-1448