Provider Demographics
NPI:1376644625
Name:ROBERT J FANNING, JR
Entity Type:Organization
Organization Name:ROBERT J FANNING, JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:304-242-1273
Mailing Address - Street 1:1307 MOUNT DE CHANTAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6334
Mailing Address - Country:US
Mailing Address - Phone:304-242-1273
Mailing Address - Fax:304-242-1422
Practice Address - Street 1:1307 MOUNT DE CHANTAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6334
Practice Address - Country:US
Practice Address - Phone:304-242-1273
Practice Address - Fax:304-242-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1431174400000X
WV46155363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6001141Medicaid
WVFA0758261Medicare ID - Type Unspecified
WVF51859Medicare UPIN