Healthcare Provider Details

I. General information

NPI: 1033778170
Provider Name (Legal Business Name): FAIRMONT CHILDRENS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 BURKE RD STE 200
PASADENA TX
77504-3451
US

IV. Provider business mailing address

4002 BURKE RD STE 100
PASADENA TX
77504-3451
US

V. Phone/Fax

Practice location:
  • Phone: 832-241-3540
  • Fax: 832-241-3750
Mailing address:
  • Phone: 832-241-3540
  • Fax: 832-241-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JILLY VIDYASAGDRAN
Title or Position: AUTHORIZED SIGNER
Credential: MD
Phone: 832-241-3540