Provider Demographics
NPI:1568772820
Name:FAIRMOUNT PODIATRY GROUP
Entity Type:Organization
Organization Name:FAIRMOUNT PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:FAHMIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-526-4266
Mailing Address - Street 1:7524 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3746
Mailing Address - Country:US
Mailing Address - Phone:510-526-4244
Mailing Address - Fax:510-526-9251
Practice Address - Street 1:7524 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3746
Practice Address - Country:US
Practice Address - Phone:510-526-4244
Practice Address - Fax:510-526-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3401213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11676Medicare UPIN
CA5097060001Medicare NSC
CAT11682Medicare UPIN