Covered Entity Details

DSH490063AP INOVA FAIRFAX HOSPITAL (Active) - information as of 5/12/2025 10:05:33 PM

Main Details

Name

INOVA FAIRFAX HOSPITAL

Subdivision Name

Inova Fairfax Hospital: Neurology Clinic - Neurology Clinic at ICPH

Type

Disproportionate Share Hospital

Rural

340B ID

DSH490063AP

Medicare Provider Number

490063

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/13/2023

Participating Start Date

10/1/2023

Participating Approval Date

9/1/2023

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Inova Fairfax
anuj steve narang, President
(480) 737-1397

Primary Contact

Inova Fairfax Medical Campus
Christiana Showunmi, 340B Program Manager
(240) 483-3843

Addresses

Street Address

8081 Innovation Park Drive
Building A
Suite 900
Fairfax, VA 22031-4867

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
VA	4900634	1831220714

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH490063A	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Infusion Center: ISCI Peds Infusion	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AA	Child	DSH	INOVA FAIRFAX HOSPITAL	RiverStone Clinic - Surgical Breast Clinc	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AB	Child	DSH	INOVA FAIRFAX HOSPITAL	Skyline Clinic - Malignant & Benign Clinic	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AC	Child	DSH	INOVA FAIRFAX HOSPITAL	White Oak Clinic - Head & Neck/ Neuro/ Palliative/ Endocrine/Thoracic Clinic/Geriatric Onc/Adv Solid Tumor	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AD	Child	DSH	INOVA FAIRFAX HOSPITAL	Infusion Center- IFH EAST - Mark Center Infusion	1800 N Beauregard St	Alexandria	VA	Active
DSH490063AE	Child	DSH	INOVA FAIRFAX HOSPITAL	Great Falls Clinic - GI,GU	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AF	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Ewing FACT Department- Alexandria - Forensic Assessment and Consultation Teams	4700 King Street	Alexandria	VA	Active
DSH490063AG	Child	DSH	INOVA FAIRFAX HOSPITAL	Fairfax Hospital -ISCI Clinic -Fairfax West - Hematology Oncology	3580 Joseph Siewick Drive	Fairfax	VA	Active
DSH490063AH	Child	DSH	INOVA FAIRFAX HOSPITAL	Interventional Pulmonology- ISCI - Interventional Pulmonology	8081 Innovation Park Dr	Fairfax	VA	Terminated
DSH490063AJ	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Infusion Center: Loudoun Infusion	44045 Riverside Parkway	Leesburg	VA	Active
DSH490063AK	Child	DSH	INOVA FAIRFAX HOSPITAL	Fairfax Hospital- ISCI Clinic- Fairfax East - Mark Center Clinic	1800 N Beauregard St	Alexandria	VA	Active
DSH490063AL	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital - ISCI Clinic - IFH Loudoun - Oncology	44055 Riverside Parkway	Leesburg	VA	Active
DSH490063AM	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurology Clinic - Neurology Clinic at Alexandria	1500 N Beauregard St	Alexandria	VA	Active
DSH490063AN	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Clinic - IFH ISCI Clinic: Phase 1 Research	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AP	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurology Clinic - Neurology Clinic at ICPH	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AQ	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Saville Center - Saville Prevention and Screening Center Clinic	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AR	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Saville Center - Saville Prevention and Screening Center Procedural Area	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AS	Child	DSH	INOVA FAIRFAX HOSPITAL	ICPH Pre Abdominal Transplant Clinic - Transplant	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AT	Child	DSH	INOVA FAIRFAX HOSPITAL	ICPH Post Abdominal Transplant Clinic - Transplant	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AU	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at Dumfries - Neurosurgery	3800 Fettler Park	Dumfries	VA	Active
DSH490063AV	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurology Clinic - Neurology Clinic at Dumfries - Neurology	3800 Fettler Park	Dumfries	VA	Active
DSH490063AW	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at Alexandria - Neurosurgery	1500 N Beauregard St	Alexandria	VA	Active
DSH490063AX	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at ICPH - Neurosurgery	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AY	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Clinic - Survivorship - Survivorship	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063AZ	Child	DSH	INOVA FAIRFAX HOSPITAL	Pain Management - ICPH - Pain Management	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063B	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Infusion Center: Adult Infusion	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063BA	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Infusion Center - Cellular Therapy - Cellular Therapy	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063BB	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH ISCI Infusion Center - Phase 1 Research - Phase 1 Research	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063C	Child	DSH	INOVA FAIRFAX HOSPITAL	Woodburn Surgery Center	3289 Woodburn Road	Annandale	VA	Active
DSH490063D	Child	DSH	INOVA FAIRFAX HOSPITAL	Imaging Center- Gainesville	13575 Heathcote Blvd.	Gainesville	VA	Active
DSH490063E	Child	DSH	INOVA FAIRFAX HOSPITAL	Vein and Vascular Center	13575 Heathcote Blvd.	Gainesville	VA	Terminated
DSH490063F	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center	4315 Chain Bridge Road	Fairfax	VA	Active
DSH490063G	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center	11901 Baron Cameron Ave	Reston	VA	Active
DSH490063H	Child	DSH	INOVA FAIRFAX HOSPITAL	Woodburn Post Anethesia Care Unit	3289 Woodburn Road	Annandale	VA	Active
DSH490063J	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center - Reston / Laboratory	11901 Baron Cameron Ave	Reston	VA	Terminated
DSH490063K	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Fairfax Hospital - Reston / X-Ray	11901 Baron Cameron Ave	Reston	VA	Terminated
DSH490063L	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center - Fairfax / Laboratory	4315 Chain Bridge Road	Fairfax	VA	Terminated
DSH490063M	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center - Fairfax / X-Ray	4315 Chain Bridge Road	Fairfax	VA	Terminated
DSH490063N	Child	DSH	INOVA FAIRFAX HOSPITAL	Emergency Care Center - Fairfax / CT Scanner	4315 Chain Bridge Road	Fairfax	VA	Active
DSH490063P	Child	DSH	INOVA FAIRFAX HOSPITAL	IFH West Infusion Center	3580 Joseph Siewick Drive	Fairfax	VA	Active
DSH490063Q	Child	DSH	INOVA FAIRFAX HOSPITAL	Radiation Oncology - ISCI Oncology	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063R	Child	DSH	INOVA FAIRFAX HOSPITAL	Cardiac Diagnostics - ISCI Cardiology	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063S	Child	DSH	INOVA FAIRFAX HOSPITAL	Arlington Blvd Cardiology - Arlington Blvd Cardiology	8505 Arlington Blvd	Fairfax	VA	Terminated
DSH490063T	Child	DSH	INOVA FAIRFAX HOSPITAL	Chesapeake Clinic - Melanoma Dermatology Oncology Clinic	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063U	Child	DSH	INOVA FAIRFAX HOSPITAL	Abdominal Transplant Clinic - Pre-Kidney Transplant	3300 Gallows Road	Falls Church	VA	Terminated
DSH490063V	Child	DSH	INOVA FAIRFAX HOSPITAL	Abdominal Transplant Clinic - Post Transplant Abdominal	3300 Gallows Road	Falls Church	VA	Terminated
DSH490063W	Child	DSH	INOVA FAIRFAX HOSPITAL	Inova Ewing FACT Department - Forensic Assessment and Consultation Teams	2671 Avenir Place	Vienna	VA	Active
DSH490063X	Child	DSH	INOVA FAIRFAX HOSPITAL	Potomac Clinic - Medical Breast Clinic	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063Y	Child	DSH	INOVA FAIRFAX HOSPITAL	Peds Sedation Services - ISCI Peds Sedation Services	8081 Innovation Park Drive	Fairfax	VA	Active
DSH490063Z	Child	DSH	INOVA FAIRFAX HOSPITAL	Diagnostic Imaging - ISCI Diagnostic Imaging	8081 Innovation Park Drive	Fairfax	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/29/2024 3:29:46 PM	8/29/2024 3:29 PM
Addresses	Main Address	Update	Change Request	8081 Innovation Park Drive Building A Fairfax, VA 22031-4867	8081 Innovation Park Drive Building A Suite 900 Fairfax, VA 22031-4867	8/6/2024 11:10 AM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		narang, anuj steve President Inova Fairfax 4807371397	9/1/2023 1:08 PM
Details	340B ID	Update	New Registration		DSH490063AP	9/1/2023 1:08 PM
Details	Entity Subname	Update	New Registration	Inova Fairfax Hospital: Neurology Clinic	Inova Fairfax Hospital: Neurology Clinic - Neurology Clinic at ICPH	9/1/2023 1:08 PM
Dates	Participating Approval Date	Update	New Registration		9/1/2023 1:08:24 PM	9/1/2023 1:08 PM
Details	State	Update	New Registration	Pending	Approved	9/1/2023 1:08 PM
Dates	Signed By Date	Update	New Registration		8/30/2023 10:41:24 AM	9/1/2023 1:08 PM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	9/1/2023 1:08 PM
Addresses	Main Address	Insert	New Registration		8081 Innovation Park Drive Building A Fairfax, VA 22031-4867	7/13/2023 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/13/2023 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4900634	7/13/2023 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	7/13/2023 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831220714	7/13/2023 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	7/13/2023 2:48 PM
Contacts	Authorizing Official	Insert	New Registration		narang, anuj steve President Inova Fairfax 4807371397	7/13/2023 2:48 PM
Contacts	Primary Contact	Insert	New Registration		Showunmi, Christiana 340B Program Manager Inova Fairfax Medical Campus 2404833843	7/13/2023 2:48 PM
Details	Assistance Received From Date	Insert	New Registration			7/13/2023 2:48 PM
Details	Assistance Received To Date	Insert	New Registration			7/13/2023 2:48 PM
Details	Last Recertification Date	Insert	New Registration			7/13/2023 2:48 PM
Details	Grant Number	Insert	New Registration			7/13/2023 2:48 PM
Details	340B ID	Insert	New Registration			7/13/2023 2:48 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/13/2023 2:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/13/2023 2:48 PM
Details	Medicare Provider Number	Insert	New Registration		490063	7/13/2023 2:48 PM
Details	Entity Name	Insert	New Registration		INOVA FAIRFAX HOSPITAL	7/13/2023 2:48 PM
Details	NOFO Number	Insert	New Registration			7/13/2023 2:48 PM
Details	Program Code	Insert	New Registration		DSH	7/13/2023 2:48 PM
Details	Entity Subname	Insert	New Registration		Inova Fairfax Hospital: Neurology Clinic	7/13/2023 2:48 PM
Dates	Participating Approval Date	Insert	New Registration			7/13/2023 2:48 PM
Details	State	Insert	New Registration		Pending	7/13/2023 2:48 PM
Dates	Registration Date	Insert	New Registration		7/13/2023 2:48:31 PM	7/13/2023 2:48 PM
Dates	Signed By Date	Insert	New Registration			7/13/2023 2:48 PM
Dates	Start Date	Insert	New Registration			7/13/2023 2:48 PM
Terminations	Termination Comments	Insert	New Registration			7/13/2023 2:48 PM
Terminations	Termination Date	Insert	New Registration			7/13/2023 2:48 PM
Terminations	Termination Effective Date	Insert	New Registration			7/13/2023 2:48 PM
Terminations	Termination Reason	Insert	New Registration			7/13/2023 2:48 PM