=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407989759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRVIEW HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 CAMPUS DR SUITE 210
-----------------------------------------------------
City | DALY CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94015-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-994-3000
-----------------------------------------------------
Fax | 650-994-3004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22338 SHARON LN
-----------------------------------------------------
City | FAIRVIEW PARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44126-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-779-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN
-----------------------------------------------------
Name | DR. MERLITA BORJA EVANGELISTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-779-1615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 33899
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------