Provider Demographics
NPI:1386962694
Name:FITZGERALD, JAIDA CELESTE (MD)
Entity type:Individual
Prefix:
First Name:JAIDA
Middle Name:CELESTE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAIDA
Other - Middle Name:CELESTE
Other - Last Name:BOURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-8218
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA255059207L00000X
390200000X
MI4301116656207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program