Provider Demographics
NPI:1720349210
Name:FACIONE, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FACIONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 CLEVELAND AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9670
Mailing Address - Country:US
Mailing Address - Phone:269-429-9644
Mailing Address - Fax:269-429-4002
Practice Address - Street 1:5515 CLEVELAND AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9670
Practice Address - Country:US
Practice Address - Phone:269-429-9644
Practice Address - Fax:269-429-4002
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720349210Medicaid
MIMI2051288Medicare PIN