Healthcare Provider Details

I. General information

NPI: 1700048915
Provider Name (Legal Business Name): JONATHON FABER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2008
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42350 GRAND RIVER AVE
NOVI MI
48375-1838
US

IV. Provider business mailing address

42350 GRAND RIVER AVE
NOVI MI
48375-1838
US

V. Phone/Fax

Practice location:
  • Phone: 248-697-2942
  • Fax: 248-436-6628
Mailing address:
  • Phone: 248-697-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101017744
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34.010276
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101017744
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: