Basic Information
| Provider Information | |||||||||
| NPI: | 1295793594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE ASSOCIATES IN LABORATORY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9834 BUSINESS WAY | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032571440 | ||||||||
| FaxNumber: | 7032574337 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 OWEN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106154000 | ||||||||
| FaxNumber: | 7032571440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOLFORD | ||||||||
| AuthorizedOfficialFirstName: | JERALD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7032571440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8901571 | 05 | NC | MEDICAID |