1215949896 NPI number — MICHAEL W FAIRBANKS FNP

Table of content: MICHAEL W FAIRBANKS FNP (NPI 1215949896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215949896 NPI number — MICHAEL W FAIRBANKS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRBANKS
Provider First Name:
MICHAEL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1215949896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7421 JOE FOUNTAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564-9626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-238-9149
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2490 PASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39531-2838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-207-9967
Provider Business Practice Location Address Fax Number:
228-273-1532
Provider Enumeration Date:
08/12/2006

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: 363L00000X , with the licence number:  1-066504 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02672857 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900279914 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1-066504 . This is a "NURSE PRACTITIONERS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 811413110 . This is a "TAX ID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 900279914 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 900279914 . This is a "MS PHYSICIAN CARE NETWORK" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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