Provider Demographics
NPI:1609040864
Name:FAIRFAX MEDICAL FACILITIES INC
Entity Type:Organization
Organization Name:FAIRFAX MEDICAL FACILITIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-642-3100
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035
Practice Address - Country:US
Practice Address - Phone:918-885-4640
Practice Address - Fax:918-885-4644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX MEDICAL FACILITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-18
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QF0400X
OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200071420EMedicaid
OK200071420EMedicaid
OK300522212Medicare PIN
OK371842Medicare Oscar/Certification