Healthcare Provider Details

I. General information

NPI: 1821055609
Provider Name (Legal Business Name): FAIRFAX NEONATAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 05/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 WILLIAMS DRIVE SUITE 520
FAIRFAX VA
22031-4648
US

IV. Provider business mailing address

3060 WILLIAMS DRIVE SUITE 520
FAIRFAX VA
22031-4648
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-1400
  • Fax: 703-289-1414
Mailing address:
  • Phone: 703-289-1400
  • Fax: 703-289-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY EDWARD BENGSTON
Title or Position: EVP, COO
Credential:
Phone: 703-289-1422