=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861433674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFAX PET IMAGING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8503 ARLINGTON BLVD SUITE LL100
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-698-4444
-----------------------------------------------------
Fax | 703-698-2176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2722 MERRILEE DR SUITE 230
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-698-4444
-----------------------------------------------------
Fax | 703-698-2176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JAMES P EARLS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-698-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------