Provider Demographics
NPI:1992718712
Name:FAIRCHILD, EDWARD (CO, CPED)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:CO, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 STATE ST
Mailing Address - Street 2:COLONIAL PLAZA
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901
Mailing Address - Country:US
Mailing Address - Phone:607-348-0343
Mailing Address - Fax:607-348-0347
Practice Address - Street 1:477 STATE ST
Practice Address - Street 2:COLONIAL PLAZA
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-348-0343
Practice Address - Fax:607-348-0347
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCO003702225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02408313Medicaid
NY4725040001Medicare ID - Type Unspecified