Provider Demographics
NPI:1043392434
Name:FAIR RIDGE OB/GYN ASSOCIATES , PC
Entity Type:Organization
Organization Name:FAIR RIDGE OB/GYN ASSOCIATES , PC
Other - Org Name:WALTER J. HODGES JR. MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-264-7801
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR
Mailing Address - Street 2:400
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1756
Mailing Address - Country:US
Mailing Address - Phone:703-264-7801
Mailing Address - Fax:703-264-7807
Practice Address - Street 1:4001 FAIR RIDGE DR
Practice Address - Street 2:202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-591-2223
Practice Address - Fax:703-591-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00665Medicare ID - Type Unspecified