Provider Demographics
NPI:1659456705
Name:FAHRMANN, JUNE MARILYN (MD)
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:MARILYN
Last Name:FAHRMANN
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 22220
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-0220
Mailing Address - Country:US
Mailing Address - Phone:763-533-2534
Mailing Address - Fax:
Practice Address - Street 1:3819 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2207
Practice Address - Country:US
Practice Address - Phone:763-533-2534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN992526100Medicaid
MNG19761Medicare UPIN
MN992526100Medicaid