Provider Demographics
NPI:1639167109
Name:FAHRNER, JOYCE RENICK (MD)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:RENICK
Last Name:FAHRNER
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 1:302 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2044
Mailing Address - Country:US
Mailing Address - Phone:810-762-8400
Mailing Address - Fax:810-762-8118
Practice Address - Street 1:302 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2044
Practice Address - Country:US
Practice Address - Phone:810-762-8400
Practice Address - Fax:810-762-8118
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030266207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4535048Medicaid
MI4535048Medicaid
0N97770Medicare PIN
ON77070Medicare ID - Type Unspecified