Provider Demographics
NPI:1447245279
Name:FAIRFAX MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:FAIRFAX MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:GILLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-426-7228
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:300 SOUTH PARK ST
Mailing Address - City:FAIRFAX
Mailing Address - State:MN
Mailing Address - Zip Code:55332-0529
Mailing Address - Country:US
Mailing Address - Phone:507-426-7228
Mailing Address - Fax:507-426-8257
Practice Address - Street 1:300 PARK ST S
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MN
Practice Address - Zip Code:55332-3153
Practice Address - Country:US
Practice Address - Phone:507-426-7228
Practice Address - Fax:507-426-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0105551OtherMEDICA
109697OtherU-CARE
1013965OtherPREFERRED ONE
MN47164GIOtherBCBS
HP21655OtherHEALTH PARTNERS
773742OtherWORLD INS
HP21655OtherHEALTH PARTNERS
HP21655OtherHEALTH PARTNERS