Provider Demographics
NPI:1295739134
Name:MICHAEL J FAZIO, MD, SURGERY CENTER
Entity type:Organization
Organization Name:MICHAEL J FAZIO, MD, SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKOWIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-492-1828
Mailing Address - Street 1:FILE # 74529
Mailing Address - Street 2:PO BOX 60000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160
Mailing Address - Country:US
Mailing Address - Phone:916-492-1828
Mailing Address - Fax:916-492-1834
Practice Address - Street 1:2805 J ST
Practice Address - Street 2:STE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4307
Practice Address - Country:US
Practice Address - Phone:916-492-1828
Practice Address - Fax:916-492-1834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLN 670261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14633ZMedicare ID - Type Unspecified