1205942463 NPI number — DR. GREGORY G FAIMON MD

Table of content: DR. GREGORY G FAIMON MD (NPI 1205942463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205942463 NPI number — DR. GREGORY G FAIMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIMON
Provider First Name:
GREGORY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205942463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 E 93RD ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY CENTER
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67147-8716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-650-2878
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2610 N WOODLAWN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67220-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-858-2610
Provider Business Practice Location Address Fax Number:
316-858-2793
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  04-27023 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 0427023 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100294640H , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100294640M , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00615213 . This is a "RR MC (PALMETTO)" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100294640L , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100294640W , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105234 . This is a "BC/BS OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200362720C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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