MEDICARE: FAIRFAX MEDICAL LABORATORIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	49D0221827	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	690001517	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104852573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRFAX MEDICAL LABORATORIES, INC.

Provider Business Mailing Address
First Line	:	4200 PLEASANT VALLEY RD
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1211
Country	:	US
Telephone Number	:	703-222-2313
Fax Number	:	703-263-2582

Provider Business Practice Location Address
First Line	:	4200 PLEASANT VALLEY RD
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1211
Country	:	US
Telephone Number	:	703-222-2313
Fax Number	:	703-263-2582

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. ROBERT FREDERICKS
Credential	:
Telephone Number	:	703-222-2313

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	01/10/2013

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