Healthcare Provider Details

I. General information

NPI: 1427169507
Provider Name (Legal Business Name): FAIRFAX COLON & RECTAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROPERSITY AVE STE 200
FAIRFAX VA
22031
US

IV. Provider business mailing address

2710 PROPERSITY AVE STE 200
FAIRFAX VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 703-280-2841
  • Fax: 703-650-2322
Mailing address:
  • Phone: 703-280-2841
  • Fax: 703-650-2322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL DELAC
Title or Position: ADMINISTRATOR
Credential: CMPE
Phone: 703-650-2333