Provider Demographics
NPI:1326002353
Name:FAHIE, LORETTE VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:LORETTE
Middle Name:VANESSA
Last Name:FAHIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6869 OCCIDENTAL HWY
Mailing Address - Street 2:P.O. BOX 130
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286
Mailing Address - Country:US
Mailing Address - Phone:517-423-6803
Mailing Address - Fax:517-423-7257
Practice Address - Street 1:6869 OCCIDENTAL HWY
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286
Practice Address - Country:US
Practice Address - Phone:517-423-6803
Practice Address - Fax:517-423-7257
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILF075422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4165036Medicaid
MIOM95140Medicare ID - Type Unspecified
MIH10576Medicare UPIN