Provider Demographics
NPI:1861488074
Name:FAIRCHILD, SU (MD)
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-0974
Mailing Address - Country:US
Mailing Address - Phone:703-828-4485
Mailing Address - Fax:888-414-5264
Practice Address - Street 1:6138 REDWOOD SQUARE CTR STE 204
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-4264
Practice Address - Country:US
Practice Address - Phone:703-229-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069929L207QA0401X, 207Q00000X
VA0101250992207QA0401X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001122151Medicaid
PA001122151Medicaid