Basic Information
| Provider Information | |||||||||
| NPI: | 1811942311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRHILL FAMILY MEDICINE SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 FAIR HILL DR | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219212512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106207260 | ||||||||
| FaxNumber: | 4106207262 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 FAIR HILL DR | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219212512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106207260 | ||||||||
| FaxNumber: | 4106207262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | BONNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4106207260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 189CFA | 01 | MD | CAREFIRST GROUP NUMBER | OTHER | DE0145 | 01 | MD | MCR RAILROAD GROUP | OTHER |