Provider Demographics
NPI:1962460071
Name:FIDELIS DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:FIDELIS DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-408-2488
Mailing Address - Street 1:11601 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0509
Mailing Address - Country:US
Mailing Address - Phone:877-408-2488
Mailing Address - Fax:866-776-6641
Practice Address - Street 1:11601 WILSHIRE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-0509
Practice Address - Country:US
Practice Address - Phone:877-408-2488
Practice Address - Fax:866-776-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTS129Medicare ID - Type UnspecifiedTRAILBLAZER
CAZZZ28892ZMedicare ID - Type UnspecifiedNHIC - NORTHERN
AZZ107386Medicare ID - Type UnspecifiedNORIDIAN
CATG482Medicare ID - Type UnspecifiedNHIC SOUTHERN