Healthcare Provider Details

I. General information

NPI: 1093409310
Provider Name (Legal Business Name): FIDELIS MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 MAIN ST
PATERSON NJ
07503-2212
US

IV. Provider business mailing address

101 CRAWFORDS CORNER RD STE 1014R
HOLMDEL NJ
07733-1976
US

V. Phone/Fax

Practice location:
  • Phone: 973-510-2444
  • Fax: 973-278-2818
Mailing address:
  • Phone: 605-915-3202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AIJUAN WANG
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 732-221-6870