Basic Information
| Provider Information | |||||||||
| NPI: | 1356501753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INOVA FAIRFAX HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1504 LINCOLN WAY | ||||||||
| Address2: | UNIT 118 | ||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221025851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175754718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037767834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHILO | ||||||||
| AuthorizedOfficialFirstName: | NATALIE | ||||||||
| AuthorizedOfficialMiddleName: | REBECCA | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9175754718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 0116018750 | VA | N | Ambulatory Health Care Facilities | Clinic/Center | 282NC0060X | 0116018750 | VA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC2000X | 0116018750 | VA | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.