Provider Demographics
NPI:1700510898
Name:FAIRWAY CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:FAIRWAY CHILDREN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKYLN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-630-8762
Mailing Address - Street 1:2434 S TAPESTRY WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-6409
Mailing Address - Country:US
Mailing Address - Phone:909-630-8762
Mailing Address - Fax:
Practice Address - Street 1:2707 E VALLEY BLVD STE 215
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3197
Practice Address - Country:US
Practice Address - Phone:909-594-3382
Practice Address - Fax:626-667-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA130711OtherCA MD STATE LICENSE #
CA1447544333OtherINDIVIDUAL TYPE 1 NPI