Provider Demographics
NPI:1114902509
Name:FAIRFAX RADIOLOGICAL CONSULTANTS PC
Entity Type:Organization
Organization Name:FAIRFAX RADIOLOGICAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-698-4483
Mailing Address - Street 1:2722 MERRILEE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4483
Mailing Address - Fax:703-573-0880
Practice Address - Street 1:2722 MERRILEE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4400
Practice Address - Country:US
Practice Address - Phone:703-698-4483
Practice Address - Fax:703-573-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA224404OtherANTHEM BCBS
VA231506OtherANTHEM BCBS
VA089016OtherANTHEM BCBS
VA089072OtherANTHEM BCBS
VA189293OtherANTHEM BCBS
VA2325664OtherUNITED HEALTH CARE
8560910OtherAETNA NON HMO
484920OtherNCPPO
MD6558011 00Medicaid
VA115091OtherANTHEM BCBS
VA189288OtherANTHEM BCBS
VA234149OtherANTHEM BCBS
VA033140OtherANTHEM BCBS
100497OtherKAISER
VA231507OtherANTHEM BCBS
VA258371OtherANTHEM BCBS
VA258372OtherANTHEM BCBS
3995OtherCAREFIRST
VA033140OtherANTHEM
VA089044OtherANTHEM BCBS
VA189289OtherANTHEM BCBS
VA2251430OtherMAMSI - OFFICE
VA302282OtherANTHEM BCBS
VA088987OtherANTHEM BCBS
VA224403OtherANTHEM BCBS
VA231507OtherANTHEM
WV4000503-000Medicaid
VA453969OtherANTHEM BCBS
9363OtherAETNA HMO
VA314478OtherMAMSI
7364052001OtherCIGNA
=========OtherGREATWEST
MD6558011 00Medicaid
VA033140OtherANTHEM
VA088987OtherANTHEM BCBS
VA089044OtherANTHEM BCBS
VA231506OtherANTHEM BCBS
VA231507OtherANTHEM BCBS
VA234149OtherANTHEM BCBS
=========OtherTRICARE
VA189293OtherANTHEM BCBS