Provider Demographics
NPI:1417133398
Name:FAIRFAX RADIOLOGICAL CONSULTANTS PC
Entity Type:Organization
Organization Name:FAIRFAX RADIOLOGICAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-698-4483
Mailing Address - Street 1:PO BOX 3650
Mailing Address - Street 2:
Mailing Address - City:MERRIFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22116-3650
Mailing Address - Country:US
Mailing Address - Phone:703-698-4444
Mailing Address - Fax:703-573-0880
Practice Address - Street 1:115 PARK ST SE
Practice Address - Street 2:STE 203
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4653
Practice Address - Country:US
Practice Address - Phone:703-698-4483
Practice Address - Fax:703-573-0880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX RADIOLOGICAL CONSULTANTS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-10
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 261QR0200X
VA221597261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA224404OtherANTHEM BCBS
VA100497OtherKAISER
VA9363OtherAETNA
VA100497OtherKAISER