Provider Demographics
NPI:1750668109
Name:THOMAS M. FOGARTY MD PC
Entity Type:Organization
Organization Name:THOMAS M. FOGARTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DONAHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-383-6933
Mailing Address - Street 1:10369 DEMOCRACY LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2548
Mailing Address - Country:US
Mailing Address - Phone:703-383-6933
Mailing Address - Fax:703-383-6936
Practice Address - Street 1:10369 DEMOCRACY LN
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2548
Practice Address - Country:US
Practice Address - Phone:703-383-6933
Practice Address - Fax:703-383-6936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA569091Medicare PIN
VAD76193Medicare UPIN