Provider Demographics
NPI:1619976479
Name:FAHEY, SEAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:FAHEY
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 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:
Practice Address - Street 1:128 MEDICAL PARK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8578
Practice Address - Country:US
Practice Address - Phone:704-658-1001
Practice Address - Fax:704-658-1002
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201576207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134NKMedicaid
NC89134NKMedicaid
2012937CMedicare PIN
P00235435Medicare PIN