Basic Information
| Provider Information | |||||||||
| NPI: | 1619133295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INOVA FAIRFAX HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791128 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212791128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3650 JOSEPH SIEWICK DR | ||||||||
| Address2: | SUITE 4TH FLOOR | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2008 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRUEGGEMANN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | HOUSESTAFF | ||||||||
| AuthorizedOfficialTelephone: | 8044759165 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.