Basic Information
| Provider Information | |||||||||
| NPI: | 1932336245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLINGO-FAHLBERG | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SPRING FOREST RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276162880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198820705 | ||||||||
| FaxNumber: | 9198739821 | ||||||||
| Practice Location | |||||||||
| Address1: | 44045 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201765101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038586000 | ||||||||
| FaxNumber: | 5712096465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 09/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | MD31161 | DC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 0101057407 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1932336245 | 05 | VA | MEDICAID |