Provider Demographics
NPI:1104852573
Name:FAIRFAX MEDICAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:FAIRFAX MEDICAL LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-222-2313
Mailing Address - Street 1:4200 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1211
Mailing Address - Country:US
Mailing Address - Phone:703-222-2313
Mailing Address - Fax:703-263-2582
Practice Address - Street 1:4200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1211
Practice Address - Country:US
Practice Address - Phone:703-222-2313
Practice Address - Fax:703-263-2582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D0221827291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004980760Medicaid
DC31230500Medicaid
VA0062430Medicaid
WV38779000Medicaid
MD431418200Medicaid
690001517OtherRAILROAD MEDICARE
WV38779000Medicaid
VA004980760Medicaid