Provider Demographics
NPI:1174503023
Name:FAHEY, JEAN K (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:K
Last Name:FAHEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:610 30TH AVENUE WEST
Mailing Address - Street 2:ALEXANDRIA CLINIC PA
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVENUE WEST
Practice Address - Street 2:ALEXANDRIA CLINIC PA
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D64118Medicare UPIN