=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073700845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFAX UROLOGY ASSOCIATES LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10875 MAIN ST SUITE 208
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-591-5443
-----------------------------------------------------
Fax | 703-591-0486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10875 MAIN ST SUITE 208
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-591-5443
-----------------------------------------------------
Fax | 703-591-0486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO OWNER
-----------------------------------------------------
Name | DR. WILLIAM LLOYD GLOVER JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-591-5443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 0101022555
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------