Provider Demographics
NPI:1104024397
Name:JOHN M FAGGARD III, MD
Entity Type:Organization
Organization Name:JOHN M FAGGARD III, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAGGARD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:208-265-5916
Mailing Address - Street 1:1005 HIGHWAY 2 W
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1702
Mailing Address - Country:US
Mailing Address - Phone:208-265-5916
Mailing Address - Fax:208-255-2066
Practice Address - Street 1:1005 HIGHWAY 2 W
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1702
Practice Address - Country:US
Practice Address - Phone:208-265-5916
Practice Address - Fax:208-255-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6916207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1226300001Medicare NSC
ID1368776Medicare PIN