Provider Demographics
NPI:1447206776
Name:FAIRBANKS, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:FAIRBANKS
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:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-742-4583
Mailing Address - Fax:989-742-4298
Practice Address - Street 1:205 S BRADLEY HWY
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-2137
Practice Address - Country:US
Practice Address - Phone:989-734-2052
Practice Address - Fax:989-734-7390
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMF051895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4134559Medicaid
MI4888306Medicaid
MI4134577Medicaid
MI0F060160OtherMEDICARE BILL PAY TO
MI4134568Medicaid
MI4888306Medicaid
MI4134577Medicaid