Healthcare Provider Details

I. General information

NPI: 1356501753
Provider Name (Legal Business Name): INOVA FAIRFAX HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD DEPARTMENT OF PEDIATRICS
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

1504 LINCOLN WAY UNIT 118
MC LEAN VA
22102-5851
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-7834
  • Fax:
Mailing address:
  • Phone: 917-575-4718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0116018750
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number0116018750
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number0116018750
License Number StateVA

VIII. Authorized Official

Name: DR. NATALIE REBECCA SHILO
Title or Position: RESIDENT
Credential: MD
Phone: 917-575-4718