Provider Demographics
NPI:1235272865
Name:FAHEY, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:FAHEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-625-6820
Mailing Address - Fax:248-625-6821
Practice Address - Street 1:6825 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-625-6820
Practice Address - Fax:248-625-6821
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F300730OtherBCBS
MI650F300730OtherBCBS