Provider Demographics
NPI:1689991036
Name:FAZEKAS-GRUBB, NANCY (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FAZEKAS-GRUBB
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 1:4030 MASSILLON RD C
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-6114
Mailing Address - Country:US
Mailing Address - Phone:330-699-1500
Mailing Address - Fax:330-699-1646
Practice Address - Street 1:4030 MASSILLON RD
Practice Address - Street 2:SUITE C
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-6114
Practice Address - Country:US
Practice Address - Phone:330-699-1500
Practice Address - Fax:330-699-1646
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH094843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3047072Medicaid
OH3047072Medicaid