Provider Demographics
NPI:1417938762
Name:FANNING, JOHN ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ELLIOTT
Last Name:FANNING
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 1:420 LOWELL DR SE
Mailing Address - Street 2:STE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-535-5954
Practice Address - Street 1:301 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-536-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22224207R00000X
AL222224208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558693Medicaid
AL51007557OtherBLUE CROSS BLUE SHIELD
0004265233OtherAETNA IDENTIFICATION NO
AL000007557Medicaid
621491901OtherTAX IDENTIFICATION NO
621491901OtherTAX IDENTIFICATION NO
AL000007557Medicaid
AL51007557OtherBLUE CROSS BLUE SHIELD
AL051558693Medicare PIN