Provider Demographics
NPI:1093409310
Name:FIDELIS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:FIDELIS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AIJUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-221-6870
Mailing Address - Street 1:101 CRAWFORDS CORNER RD STE 1014R
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1976
Mailing Address - Country:US
Mailing Address - Phone:605-915-3202
Mailing Address - Fax:
Practice Address - Street 1:1042 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2212
Practice Address - Country:US
Practice Address - Phone:973-510-2444
Practice Address - Fax:973-278-2818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty