Provider Demographics
NPI:1417071697
Name:FAIRFAX FAMILY PRACTICE CENTERS PC
Entity Type:Organization
Organization Name:FAIRFAX FAMILY PRACTICE CENTERS PC
Other - Org Name:TOWN CENTER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-255-9100
Mailing Address - Street 1:PO BOX 791128
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1128
Mailing Address - Country:US
Mailing Address - Phone:703-834-1473
Mailing Address - Fax:703-318-7463
Practice Address - Street 1:12110 SUNSET HILLS ROAD
Practice Address - Street 2:LOWER LEVEL 20
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-834-1473
Practice Address - Fax:703-318-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00532Medicare PIN