MEDICARE: DAVID G FANNEY, DO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS0005960	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891075032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID G FANNEY, DO PA

Provider Business Mailing Address
First Line	:	4241 NW AMERICAN LN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-752-2246
Fax Number	:	386-758-7998

Provider Business Practice Location Address
First Line	:	4241 NW AMERICAN LN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-752-2246
Fax Number	:	386-758-7998

Authorized Official
Title or Position	:	PRISIDENT
Name	:	DR. DAVID GRAFTON FANNEY
Credential	:	D.O.
Telephone Number	:	386-752-2246

Provider Enumeration Date	:	08/19/2011
Last Update Date	:	01/27/2012

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