Healthcare Provider Details

I. General information

NPI: 1467885228
Provider Name (Legal Business Name): FAIRFAX RADIOLOGICAL CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY DR STE 120
FAIRFAX VA
22030-2503
US

IV. Provider business mailing address

2722 MERRILEE DR STE 230
FAIRFAX VA
22031-4400
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-4467
  • Fax: 703-788-8422
Mailing address:
  • Phone: 703-698-4444
  • Fax: 703-204-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS L ELLIOTT
Title or Position: CEO
Credential:
Phone: 703-698-4444