Provider Demographics
NPI:1932200599
Name:FAIR OAKS MEDICAL CARE INC.
Entity Type:Organization
Organization Name:FAIR OAKS MEDICAL CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-264-0220
Mailing Address - Street 1:12703 LAUREL GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1625
Mailing Address - Country:US
Mailing Address - Phone:703-264-0220
Mailing Address - Fax:703-264-0231
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:STE. 303
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-264-0220
Practice Address - Fax:703-264-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231908174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01125Medicare ID - Type Unspecified