Provider Demographics
NPI:1114998127
Name:FAJGENBAUM, MICHAEL CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:FAJGENBAUM
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 1:3410 EXECUTIVE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7450
Mailing Address - Country:US
Mailing Address - Phone:919-872-5296
Mailing Address - Fax:919-850-9718
Practice Address - Street 1:3410 EXECUTIVE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7450
Practice Address - Country:US
Practice Address - Phone:919-872-5296
Practice Address - Fax:919-850-9718
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32359207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8931094Medicaid
NC8931094Medicaid
204122Medicare PIN