Provider Demographics
NPI:1841247673
Name:FAIRLEY, PATRICK HUGH (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:HUGH
Last Name:FAIRLEY
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 1:26930 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053640F207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0673016Medicaid
OH942460636247OtherCARESOURCE
OHE96258Medicare UPIN
OHFA4155071Medicare ID - Type Unspecified