Provider Demographics
NPI:1265733356
Name:AMELIA FAJARDO FAMILY MEDICAL CLINIC PC
Entity type:Organization
Organization Name:AMELIA FAJARDO FAMILY MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-617-9974
Mailing Address - Street 1:4305 DIVISION AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-3315
Mailing Address - Country:US
Mailing Address - Phone:616-617-9974
Mailing Address - Fax:
Practice Address - Street 1:450 MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-8531
Practice Address - Country:US
Practice Address - Phone:269-463-3125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030837208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty