Provider Demographics
NPI:1093946295
Name:FAIRMONT ORTHOPEDICS AND SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:FAIRMONT ORTHOPEDICS AND SPORTS MEDICINE, PA
Other - Org Name:CENTER FOR SPECIALTY CARE SLEEP EYE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC ADMIN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SIEGLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-238-4949
Mailing Address - Street 1:717 S STATE ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-238-4949
Mailing Address - Fax:507-238-3377
Practice Address - Street 1:400 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:SLEEPY EYE
Practice Address - State:MN
Practice Address - Zip Code:56085-1109
Practice Address - Country:US
Practice Address - Phone:507-794-3571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0324830003Medicare NSC