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General NPI Number Information
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NPI Number | 1447245279
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Entity Type | Organization
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Legal Business Name | FAIRFAX MEDICAL CLINIC PA
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Dates
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Enumeration Date | 09/19/2005
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 300 PARK ST S
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City | FAIRFAX
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State | MN
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Zip | 55332-3153
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Country | US
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Telephone | 507-426-7228
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Fax | 507-426-8257
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Provider Business Mailing Address
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Address Line | PO BOX 529 300 SOUTH PARK ST
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City | FAIRFAX
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State | MN
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Zip | 55332-0529
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Country | US
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Telephone | 507-426-7228
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Fax | 507-426-8257
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Authorized Official
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Title or Position | PHYSICIAN
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Name | THOMAS FREDERICK GILLES
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Credential | MD
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Telephone | 507-426-7228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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