Basic Information
| Provider Information | |||||||||
| NPI: | 1568450054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIDAI MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | #380 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601239400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477419800 | ||||||||
| FaxNumber: | 8477413058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | #380 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601239400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477419800 | ||||||||
| FaxNumber: | 8477413058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VARGAS | ||||||||
| AuthorizedOfficialFirstName: | SHAZLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8477419800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.