Basic Information
| Provider Information | |||||||||
| NPI: | 1710060330 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRFAX FAMILY PRACTICE CENTERS, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY MEDICINE OF CLIFTON-CENTREVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791128 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212791128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912030 | ||||||||
| FaxNumber: | 7032733943 | ||||||||
| Practice Location | |||||||||
| Address1: | 6201 CENTREVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201212626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032639600 | ||||||||
| FaxNumber: | 7032661452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7033912030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIRFAX FAMILY PRACTICE CENTERS, PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 0631926 | VA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1548266117 | 01 | VA | NPI | OTHER | 1699771394 | 01 | VA | NPI | OTHER | 5618916 | 05 | VA | MEDICAID | CO8267 | 01 | VA | VIRGINIA MEDICARE | OTHER | G00522 | 01 | VA | MEDICARE HIGHMARK | OTHER | 1487657136 | 01 | VA | NPI | OTHER | 010072409 | 05 | VA | MEDICAID | 1790781474 | 01 | VA | NPI | OTHER | 5618959 | 05 | VA | MEDICAID | 1205944964 | 01 | VA | NPI | OTHER | 1245236926 | 01 | VA | NPI | OTHER | 5604761 | 05 | VA | MEDICAID | 5619181 | 05 | VA | MEDICAID | 11664428801 | 01 | VA | NPI | OTHER | 5619050 | 05 | VA | MEDICAID | 5619076 | 05 | VA | MEDICAID | 1063418762 | 01 | VA | NPI | OTHER |