Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | 235218 | MA |
N | 2080P0202X | Pediatric Cardiologist | 236443 | NY |
NPI | 1255536082 |
---|---|
Provider Name | Dr. Michael C. Fahey |
First Address | Boston, MA 02241-5348 |
Second Address | Worcester, MA 01655-0002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2007 |
Last Update Date | 10/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110079829A | (05) | MA |