Healthcare Provider Details

I. General information

NPI: 1437183605
Provider Name (Legal Business Name): FAIRHAVEN OBSTETRICS & GYNECOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LIGHTHOUSE LANE
GOSHEN IN
46526-3824
US

IV. Provider business mailing address

1111 LIGHTHOUSE LANE
GOSHEN IN
46526-3824
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-0348
  • Fax: 574-533-0277
Mailing address:
  • Phone: 574-533-0348
  • Fax: 574-533-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: GAYLE J BORKOWSKI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-533-0348