Provider Demographics
NPI:1376554006
Name:FAIRFAX HEALTHCARE PROPERTIES,LLC
Entity Type:Organization
Organization Name:FAIRFAX HEALTHCARE PROPERTIES,LLC
Other - Org Name:FAIRFAX MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-642-3291
Mailing Address - Street 1:HWY 18 & TAFT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-0219
Mailing Address - Country:US
Mailing Address - Phone:918-642-3291
Mailing Address - Fax:918-642-3694
Practice Address - Street 1:HWY 18 & TAFT AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-0219
Practice Address - Country:US
Practice Address - Phone:918-642-3291
Practice Address - Fax:918-642-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2274282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000370133001OtherBCBS OKLAHOMA
OK100700710AMedicaid
OKF37013301OtherMEDICARE PART B (LEGACY)
OK=========OtherTAX ID
OK000370133001OtherBCBS OKLAHOMA