Healthcare Provider Details

I. General information

NPI: 1184990004
Provider Name (Legal Business Name): ENE THERESE RAIG FAIRCHILD MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 OLENTANGY RIVER RD
COLUMBUS OH
43214
US

IV. Provider business mailing address

6549 BALLANTRAE PL
DUBLIN OH
43016-6050
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-4731
  • Fax:
Mailing address:
  • Phone: 614-209-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.123030
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.123030
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: