Healthcare Provider Details

I. General information

NPI: 1104039270
Provider Name (Legal Business Name): EDWIN RAYMOND FAJARDO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S BARRINGTON RD
BARRINGTON IL
60010-5202
US

IV. Provider business mailing address

1301 S BARRINGTON RD
BARRINGTON IL
60010-5202
US

V. Phone/Fax

Practice location:
  • Phone: 847-620-4571
  • Fax: 847-620-4575
Mailing address:
  • Phone: 847-620-4571
  • Fax: 847-620-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: