Provider Demographics
NPI:1548224579
Name:FAIRBORN FAMILY PRACTICE ASSOC
Entity Type:Organization
Organization Name:FAIRBORN FAMILY PRACTICE ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PETERANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-878-8644
Mailing Address - Street 1:850 E XENIA DRIVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-8760
Mailing Address - Country:US
Mailing Address - Phone:937-878-8644
Mailing Address - Fax:937-878-8646
Practice Address - Street 1:850 E XENIA DRIVE
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-8760
Practice Address - Country:US
Practice Address - Phone:937-878-8644
Practice Address - Fax:937-878-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002102P207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0003193OtherTRICARE
OH0220513Medicaid
OH000000005178OtherANTHEM BCBS
OH000000005178OtherANTHEM BCBS
OH0220513Medicaid