MEDICARE: DR. ESSAM A. FAWZY SA-C

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	04-137	MD

General Provider Information

NPI Number	:	1649540550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ESSAM A. FAWZY SA-C

Provider Business Mailing Address
First Line	:	12011 LEE JACKSON HWY STE 501
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3315
Country	:	US
Telephone Number	:	703-259-7027
Fax Number	:	703-591-0005

Provider Business Practice Location Address
First Line	:	12011 LEE JACKSON 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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	09/06/2018

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