Healthcare Provider Details

I. General information

NPI: 1063588895
Provider Name (Legal Business Name): FAIRCHILD MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BRUCE ST STE 500
YREKA CA
96097-3463
US

IV. Provider business mailing address

2107 LIVINGSTON ST SUITE A
OAKLAND CA
94606-5218
US

V. Phone/Fax

Practice location:
  • Phone: 530-842-3507
  • Fax:
Mailing address:
  • Phone: 510-436-9000
  • Fax: 510-436-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN MARON
Title or Position: PRESIDENT
Credential: MD
Phone: 510-436-9000