Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0207X | Pediatric Hematology-Oncologist | 4301049486 | MI |
NPI | 1245201383 |
---|---|
Provider Name | James B Fahner |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Rapids, MI 49503-2560 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2006 |
Last Update Date | 08/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1104104512 | BCBSM (01) | MI |
2571143 | (05) | MI |
F28188 | (02) | MI |