Provider Demographics
NPI:1093778557
Name:FAIRBROOK MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:FAIRBROOK MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:KESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-327-4745
Mailing Address - Street 1:1985 STARTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-8307
Mailing Address - Country:US
Mailing Address - Phone:828-327-4745
Mailing Address - Fax:828-327-0841
Practice Address - Street 1:1985 STARTOWN RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-8307
Practice Address - Country:US
Practice Address - Phone:828-327-4745
Practice Address - Fax:828-327-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890153KMedicaid
NCCJ5683OtherRAILROAD MEDICARE
NC0153KOtherBCBS
NC2185307AMedicare PIN