=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396327052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIV FAIRFAX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2021
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13135 LEE JACKSON MEMORIAL HWY STE 145
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-828-2387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14085 CROWN CT
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-763-5224
-----------------------------------------------------
Fax | 703-763-5374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ANISH P SHAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-828-2387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------