MEDICARE: FIDELIS HEALTH GROUP LLC

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
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	3336S0011X	Specialty Pharmacy	PHY52510	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2149274	OTHER		PK

General Provider Information

NPI Number	:	1316135569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIDELIS HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	1002 S BALDWIN AVE
Second Line	:
City	:	ARCADIA
State	:	CA
Zip	:	91007-7234
Country	:	US
Telephone Number	:	626-447-2138
Fax Number	:	626-447-6433

Provider Business Practice Location Address
First Line	:	1002 S BALDWIN AVE
Second Line	:
City	:	ARCADIA
State	:	CA
Zip	:	91007-7234
Country	:	US
Telephone Number	:	626-447-2138
Fax Number	:	626-447-6433

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WAGNER A LEMUS
Credential	:
Telephone Number	:	702-815-0800

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	09/20/2018

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Directions to “FIDELIS HEALTH GROUP LLC ” Practice Location

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