Provider Demographics
NPI:1609334978
Name:DR. RICHARD C. FIDANZA LLC
Entity type:Organization
Organization Name:DR. RICHARD C. FIDANZA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ SOLE OWNER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:FIDANZA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-266-9000
Mailing Address - Street 1:2770 SOLOMONS ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1211
Mailing Address - Country:US
Mailing Address - Phone:410-266-9000
Mailing Address - Fax:410-266-9058
Practice Address - Street 1:2770 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1211
Practice Address - Country:US
Practice Address - Phone:410-266-9000
Practice Address - Fax:410-266-9058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T77210OtherUPIN
MD23910070Medicaid
DW81-0000OtherCAREFIRST