Provider Demographics
NPI:1184147829
Name:FAIRFAX MEDICAL ASSOCIATES,LLC
Entity type:Organization
Organization Name:FAIRFAX MEDICAL ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ESAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AL NOUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:214-227-2457
Mailing Address - Street 1:PO BOX 45718
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-5718
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY STE 501
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3315
Practice Address - Country:US
Practice Address - Phone:703-259-7027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty