Healthcare Provider Details

I. General information

NPI: 1861488074
Provider Name (Legal Business Name): SU FAIRCHILD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 VALLEY AVE
WINCHESTER VA
22601-2755
US

IV. Provider business mailing address

PO BOX 974
BLOOMSBURG PA
17815-0974
US

V. Phone/Fax

Practice location:
  • Phone: 540-215-2211
  • Fax: 888-414-5264
Mailing address:
  • Phone: 570-391-0104
  • Fax: 888-414-5264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD069929L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number0101250992
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101250992
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD069929L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: