Provider Demographics
NPI:1679530695
Name:FAZI, BURT (MD)
Entity Type:Individual
Prefix:
First Name:BURT
Middle Name:
Last Name:FAZI
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 1:620 HOWARD AVE
Mailing Address - Street 2:BLDG 7-F
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4804
Mailing Address - Country:US
Mailing Address - Phone:814-946-2328
Mailing Address - Fax:814-946-7724
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:BLDG 7-F
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-946-2328
Practice Address - Fax:814-946-7724
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030242E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012276360001Medicaid
PA592220HRYMedicare ID - Type Unspecified
PAE34910Medicare UPIN