Provider Demographics
NPI:1942316252
Name:FAULSTICH, GARY G (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:FAULSTICH
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 1:20811 KELLY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3139
Mailing Address - Country:US
Mailing Address - Phone:586-445-2210
Mailing Address - Fax:586-445-0700
Practice Address - Street 1:20811 KELLY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3139
Practice Address - Country:US
Practice Address - Phone:586-445-2210
Practice Address - Fax:586-445-0700
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010394522084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
M1177005Medicare ID - Type Unspecified
B44767Medicare UPIN