Healthcare Provider Details

I. General information

NPI: 1770802555
Provider Name (Legal Business Name): FAIRLAWN SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 STEPHENSON AVE SW
ROANOKE VA
24014-1664
US

IV. Provider business mailing address

2030 STEPHENSON AVE SW
ROANOKE VA
24014-1664
US

V. Phone/Fax

Practice location:
  • Phone: 540-904-6170
  • Fax: 540-904-6177
Mailing address:
  • Phone: 540-904-6170
  • Fax: 540-904-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN D EVANS
Title or Position: CO-MEDICAL DIRECTOR
Credential: MD
Phone: 540-904-6170