Basic Information
| Provider Information | |||||||||
| NPI: | 1235309931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRFAX RADIOLOGICAL CONSULTANTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7035730880 | ||||||||
| Practice Location | |||||||||
| Address1: | 4315 CHAIN BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220303061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7035730880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 08/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7036984483 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIRFAX RADIOLOGICAL CONSULTANTS PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 189289 | 01 | VA | ANTHEM BCBS | OTHER |