Provider Demographics
NPI:1568450054
Name:FIDAI MEDICAL GROUP
Entity Type:Organization
Organization Name:FIDAI MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAZLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-741-9800
Mailing Address - Street 1:1710 N RANDALL RD
Mailing Address - Street 2:#380
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-9400
Mailing Address - Country:US
Mailing Address - Phone:847-741-9800
Mailing Address - Fax:847-741-3058
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:#380
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:847-741-9800
Practice Address - Fax:847-741-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL99395Medicare UPIN
ILK10321Medicare ID - Type UnspecifiedDR DAUDI IND #
ILF57773Medicare UPIN
ILI16997Medicare UPIN
IL206146Medicare ID - Type UnspecifiedGROUP PROVIDER #