Provider Demographics
NPI:1831647239
Name:FAIRFAX INTERNAL MEDICINE AND PRIMARY CARE PC
Entity Type:Organization
Organization Name:FAIRFAX INTERNAL MEDICINE AND PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KARUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-291-0405
Mailing Address - Street 1:5618 OX RD
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039
Mailing Address - Country:US
Mailing Address - Phone:703-291-0405
Mailing Address - Fax:703-337-0377
Practice Address - Street 1:5618 OX RD
Practice Address - Street 2:SUITE D-2
Practice Address - City:FAIRFAX STATION
Practice Address - State:VA
Practice Address - Zip Code:22039
Practice Address - Country:US
Practice Address - Phone:703-291-0405
Practice Address - Fax:703-337-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250312207R00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty