MEDICARE: DR. DARYL R FANNEY M.D.

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	2085R0202X	Diagnostic Radiology Physician	0101045547	VA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	380544	OTHER	VA	ANTHEM BC/BS PROV#

General Provider Information

NPI Number	:	1922081538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARYL R FANNEY M.D.

Provider Business Mailing Address
First Line	:	4668 PEMBROKE BLVD
Second Line	:	SUITE 117
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6423
Country	:	US
Telephone Number	:	757-671-1144
Fax Number	:	757-671-1265

Provider Business Practice Location Address
First Line	:	4668 PEMBROKE BLVD
Second Line	:	SUITE 117
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6423
Country	:	US
Telephone Number	:	757-671-1144
Fax Number	:	757-671-1265

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	04/22/2008

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