Provider Demographics
NPI:1962440081
Name:FAIRFAX, MARILYNN RANSOM (MD)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:RANSOM
Last Name:FAIRFAX
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 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4201 ST ANTOINE
Practice Address - Street 2:UHC 3C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058560207ZC0006X, 207ZM0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630067Medicare PIN