Provider Demographics
NPI:1073544870
Name:FAICHNEY, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FAICHNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CIRCLE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2342
Mailing Address - Country:US
Mailing Address - Phone:231-935-0545
Mailing Address - Fax:231-935-0857
Practice Address - Street 1:224 CIRCLE DR
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2342
Practice Address - Country:US
Practice Address - Phone:231-935-0545
Practice Address - Fax:231-935-0857
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037505207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3493776Medicaid
MI4878542Medicaid
MI4964551Medicaid
MIM69390023Medicare ID - Type Unspecified
MI0B86018127Medicare PIN
MI4964551Medicaid
MI4878542Medicaid