MEDICARE: FAIRFAX MEDICAL ASSOCIATES,LLC

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	246ZC0007X	Surgical Assistant		VA

General Provider Information

NPI Number	:	1184147829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRFAX MEDICAL ASSOCIATES,LLC

Provider Business Mailing Address
First Line	:	PO BOX 45718
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21297-5718
Country	:	US
Telephone Number	:	214-227-2457
Fax Number	:	214-764-0880

Provider Business Practice Location Address
First Line	:	12011 LEE JACKSON MEMORIAL HWY STE 501
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3315
Country	:	US
Telephone Number	:	703-259-7027
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ESAM AL NOUMAN
Credential	:	LSA
Telephone Number	:	214-227-2457

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	08/14/2023

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