Healthcare Provider Details

I. General information

NPI: 1780227918
Provider Name (Legal Business Name): FAIRBANKS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16089 SAN DIEGUITO RD H102
RANCHO SANTA FE CA
92067
US

IV. Provider business mailing address

PO BOX 9227
RANCHO SANTA FE CA
92067-4227
US

V. Phone/Fax

Practice location:
  • Phone: 858-255-1969
  • Fax:
Mailing address:
  • Phone: 858-255-1969
  • Fax: 858-759-6729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARTER H SIGMON
Title or Position: PRESIDENT
Credential: MD
Phone: 858-255-1969