Provider Demographics
NPI:1710060330
Name:FAIRFAX FAMILY PRACTICE CENTERS, P.C.
Entity Type:Organization
Organization Name:FAIRFAX FAMILY PRACTICE CENTERS, P.C.
Other - Org Name:FAMILY MEDICINE OF CLIFTON-CENTREVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-391-2030
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:703-391-2030
Mailing Address - Fax:703-273-3943
Practice Address - Street 1:6201 CENTREVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2626
Practice Address - Country:US
Practice Address - Phone:703-263-9600
Practice Address - Fax:703-266-1452
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX FAMILY PRACTICE CENTERS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
VA0631926261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1548266117OtherNPI
VA1699771394OtherNPI
VA5618916Medicaid
VACO8267OtherVIRGINIA MEDICARE
VAG00522OtherMEDICARE HIGHMARK
VA1487657136OtherNPI
VA010072409Medicaid
VA1790781474OtherNPI
VA5618959Medicaid
VA1205944964OtherNPI
VA1245236926OtherNPI
VA5604761Medicaid
VA5619181Medicaid
VA11664428801OtherNPI
VA5619050Medicaid
VA5619076Medicaid
VA1063418762OtherNPI
VA1699771394OtherNPI
VA5618959Medicaid