=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831123918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE OF FAIRFAX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3998 FAIR RIDGE DR SUITE 270
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-352-3522
-----------------------------------------------------
Fax | 703-352-4170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3998 FAIR RIDGE DR SUITE 270
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-352-3522
-----------------------------------------------------
Fax | 703-352-4170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NOTA HUNTER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-352-3522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------