Provider Demographics
NPI:1164448577
Name:FAIRFAX GASTROENTEROLOGY, INC.
Entity Type:Organization
Organization Name:FAIRFAX GASTROENTEROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WASEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-620-0688
Mailing Address - Street 1:PO BOX 220037
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-0037
Mailing Address - Country:US
Mailing Address - Phone:703-620-0688
Mailing Address - Fax:703-620-6628
Practice Address - Street 1:3650 JOSEPH SIEWICK DR STE 205B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1712
Practice Address - Country:US
Practice Address - Phone:703-620-0688
Practice Address - Fax:703-620-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG02121Medicare ID - Type Unspecified