Provider Demographics
NPI:1497511588
Name:FIDAMAR MEDICAL LLP
Entity Type:Organization
Organization Name:FIDAMAR MEDICAL LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAIDHERBE
Authorized Official - Middle Name:
Authorized Official - Last Name:CEUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-623-3120
Mailing Address - Street 1:451 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2721
Practice Address - Country:US
Practice Address - Phone:269-254-8400
Practice Address - Fax:269-254-8350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty