Provider Demographics
NPI:1306957485
Name:FAIRFAX COLON & RECTAL SURGERY CENTER, LLC
Entity type:Organization
Organization Name:FAIRFAX COLON & RECTAL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAC
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:703-650-2333
Mailing Address - Street 1:2710 PROSPERITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-280-2841
Mailing Address - Fax:703-650-2322
Practice Address - Street 1:2710 PROSPERITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-280-2841
Practice Address - Fax:703-650-2322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX COLON & RECTAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty