Fairfax Medical Laboratories, Inc.

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

49D0221827 Issued in VA

Legal business name

FAIRFAX MEDICAL LABORATORIES, INC.

Practice address

4200 Pleasant Valley Rd
Chantilly, VA 20151-1211

Phone

(703) 222-2313

Fax

(703) 263-2582

NPI assigned

Jun 25, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Robert Fredericks

Title

Vice President

Phone

(703) 222-2313

Specialties & licenses 1

Addresses

Other identifiers 6

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151193600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1357776000000",
    "number": "1104852573",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4200 PLEASANT VALLEY RD",
            "city": "CHANTILLY",
            "state": "VA",
            "postal_code": "201511211",
            "telephone_number": "703-222-2313",
            "fax_number": "703-263-2582"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200 PLEASANT VALLEY RD",
            "city": "CHANTILLY",
            "state": "VA",
            "postal_code": "201511211",
            "telephone_number": "703-222-2313",
            "fax_number": "703-263-2582"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRFAX MEDICAL LABORATORIES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-25",
        "last_updated": "2013-01-10",
        "status": "A",
        "authorized_official_last_name": "FREDERICKS",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "703-222-2313",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "VA",
            "license": "49D0221827",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004980760",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31230500",
            "state": "DC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0062430",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38779000",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "431418200",
            "state": "MD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "690001517",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Megan Drye Famodu, PHARMD
• Margaret Elinor Fanning

• All providers in Chantilly, VA
• Clinical Medical Laboratory in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.