Provider Demographics
NPI:1700908522
Name:FANNING, JUSTIN SHAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SHAYNE
Last Name:FANNING
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2537
Practice Address - Country:US
Practice Address - Phone:616-459-7258
Practice Address - Fax:616-459-5215
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074884208G00000X, 208G00000X
IN01063587A2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI73961Medicare UPIN
MID16173016Medicare PIN
IN941090V4Medicare PIN
MI1700908522Medicaid
IN200869490Medicaid