Provider Demographics
NPI:1053494435
Name:FANNING, JOHN M (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:FANNING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:8 MORTON AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2210
Mailing Address - Country:US
Mailing Address - Phone:610-595-6850
Mailing Address - Fax:610-595-6892
Practice Address - Street 1:8 MORTON AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2210
Practice Address - Country:US
Practice Address - Phone:610-595-6850
Practice Address - Fax:610-595-6892
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOS003967L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001454661Medicaid
PA001454661Medicaid
PA25735Medicare ID - Type Unspecified