Healthcare Provider Details

I. General information

NPI: 1891983953
Provider Name (Legal Business Name): FAIRFAX OB-GYN ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2007
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 JOSEPH SIEWICK DR SUITE 203
FAIRFAX VA
22033-1710
US

IV. Provider business mailing address

2028 OPITZ BLVD STE 1
WOODBRIDGE VA
22191-3326
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-1500
  • Fax: 703-860-1549
Mailing address:
  • Phone: 703-690-2295
  • Fax: 703-690-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA SHAH
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 202-899-1055