Healthcare Provider Details

I. General information

NPI: 1104311604
Provider Name (Legal Business Name): PEYTON PAUL FAGANEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 LEAHY ST STE 201A
MUSKEGON MI
49442
US

IV. Provider business mailing address

32 MEADOWS DR
NORTON SHORES MI
49444-7786
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-7800
  • Fax:
Mailing address:
  • Phone: 319-329-6764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number92744
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101024308
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number92744
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: