Provider Demographics
NPI:1700088242
Name:FAIRFAX NEONATAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:FAIRFAX NEONATAL ASSOCIATES, PC
Other - Org Name:PEDIATRIC SURGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-289-1448
Mailing Address - Street 1:2730 PROSPERITY AVE # B
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 PROSPERITY AVE
Practice Address - Street 2:STE C
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4329
Practice Address - Country:US
Practice Address - Phone:703-560-2236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX NEONATAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-05
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty