Provider Demographics
NPI:1437183605
Name:FAIRHAVEN OBSTETRICS & GYNECOLOGY, INC
Entity Type:Organization
Organization Name:FAIRHAVEN OBSTETRICS & GYNECOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BORKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-533-0348
Mailing Address - Street 1:1111 LIGHTHOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3824
Mailing Address - Country:US
Mailing Address - Phone:574-533-0348
Mailing Address - Fax:574-533-0277
Practice Address - Street 1:1111 LIGHTHOUSE LANE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3824
Practice Address - Country:US
Practice Address - Phone:574-533-0348
Practice Address - Fax:574-533-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100111950Medicaid
INCB5226OtherRAILROAD MEDICARE
IN100111950Medicaid