Healthcare Provider Details

I. General information

NPI: 1649437666
Provider Name (Legal Business Name): INOVA FAIRFAX HOSPITAL FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

3254 APPLEGATE CT
ANNANDALE VA
22003-1108
US

V. Phone/Fax

Practice location:
  • Phone: 832-259-2100
  • Fax:
Mailing address:
  • Phone: 832-259-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number0116019566
License Number StateVA

VIII. Authorized Official

Name: GRISELDA MANI MEZA
Title or Position: RESIDENT
Credential: M.D.
Phone: 832-259-2100