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NPI Code Detail

MEDICARE: DR. EDWARD J FAJARDO PSYD

MEDICARE: DR. EDWARD J FAJARDO PSYD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical PsychologistIL

General Provider Information

NPI Number : 1306816400
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. EDWARD J FAJARDO PSYD
Provider Business Mailing Address
First Line : 720 W GORDON TER
Second Line : 21A
City : CHICAGO
State : IL
Zip : 60613-2269
Country : US
Telephone Number : 773-296-9505
Fax Number :
Provider Business Practice Location Address
First Line : 4025 N SHERIDAN RD
Second Line :
City : CHICAGO
State : IL
Zip : 60613-2010
Country : US
Telephone Number : 773-388-8909
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/23/2006
Last Update Date : 07/08/2007

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