Provider Demographics
NPI:1073700845
Name:FAIRFAX UROLOGY ASSOCIATES LTD
Entity Type:Organization
Organization Name:FAIRFAX UROLOGY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-591-5443
Mailing Address - Street 1:10875 MAIN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4732
Mailing Address - Country:US
Mailing Address - Phone:703-591-5443
Mailing Address - Fax:703-591-0486
Practice Address - Street 1:10875 MAIN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4732
Practice Address - Country:US
Practice Address - Phone:703-591-5443
Practice Address - Fax:703-591-0486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022555208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010877OtherANTHEM
VA340013417OtherRR
VA6488OtherCAREFIRST
VA340013417OtherRR