Provider Demographics
NPI:1063588895
Name:FAIRCHILD MEDICAL GROUP
Entity type:Organization
Organization Name:FAIRCHILD MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-436-9000
Mailing Address - Street 1:2107 LIVINGSTON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-5218
Mailing Address - Country:US
Mailing Address - Phone:510-436-9000
Mailing Address - Fax:510-436-9013
Practice Address - Street 1:475 BRUCE ST STE 500
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3463
Practice Address - Country:US
Practice Address - Phone:530-842-3507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089870Medicaid
CAZZZ03208ZOtherBLUE SHIELD OF CALIFORNIA
CARHM53972FMedicaid
CAZZZ03208ZOtherBLUE SHIELD OF CALIFORNIA
CA553972Medicare Oscar/Certification