Healthcare Provider Details

I. General information

NPI: 1417133398
Provider Name (Legal Business Name): FAIRFAX RADIOLOGICAL CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PARK ST SE STE 203
VIENNA VA
22180-4653
US

IV. Provider business mailing address

PO BOX 3650
MERRIFIELD VA
22116-3650
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-4483
  • Fax: 703-573-0880
Mailing address:
  • Phone: 703-698-4444
  • Fax: 703-573-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number221597
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BILL F ALLISON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 703-698-4483