Provider Demographics
NPI:1013032283
Name:FAIRFAX FAMILY PRACTICE CENTERS PC
Entity Type:Organization
Organization Name:FAIRFAX FAMILY PRACTICE CENTERS PC
Other - Org Name:VIENNA FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-255-9100
Mailing Address - Street 1:PO BOX 791128
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1128
Mailing Address - Country:US
Mailing Address - Phone:703-255-9100
Mailing Address - Fax:703-255-3457
Practice Address - Street 1:115 PARK STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-255-9100
Practice Address - Fax:703-255-3457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX FAMILY PRACTICE CENTERS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-20
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00532Medicare PIN