Provider Demographics
NPI:1720198039
Name:FENTON FAMILY MEDICINE, P.C.
Entity Type:Organization
Organization Name:FENTON FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEIBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-750-6060
Mailing Address - Street 1:445 N FENWAY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2666
Mailing Address - Country:US
Mailing Address - Phone:810-750-6060
Mailing Address - Fax:810-750-6081
Practice Address - Street 1:445 N FENWAY DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2666
Practice Address - Country:US
Practice Address - Phone:810-750-6060
Practice Address - Fax:810-750-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKS051250261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080B56203OtherBCBS
MI2509644012OtherHEALTH PLUS
MIC3137OtherMCARE
MI2787144Medicaid
MI0B56203OtherBLUE CARE NETWORK
MIE77396OtherHAP
MI2509644012OtherHEALTH PLUS
MIE77396OtherHAP