Provider Demographics
NPI: | 1467568469 |
---|---|
Name: | FAHY, BRENDA GERALDINE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRENDA |
Middle Name: | GERALDINE |
Last Name: | FAHY |
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: | PO BOX 918025 |
Mailing Address - Street 2: | |
Mailing Address - City: | ORLANDO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32891-8025 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-273-8610 |
Mailing Address - Fax: | 352-273-8612 |
Practice Address - Street 1: | 1600 SW ARCHER RD |
Practice Address - Street 2: | |
Practice Address - City: | GAINESVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32610-3003 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-273-8610 |
Practice Address - Fax: | 352-273-8612 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-22 |
Last Update Date: | 2012-01-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 37397 | 207L00000X, 207LC0200X |
FL | ME111288 | 207LC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207LC0200X | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 004299900 | Medicaid | |
FL | 004299900 | Medicaid | |
FL | FQ542Z | Medicare PIN |