Healthcare Provider Details

I. General information

NPI: 1104144526
Provider Name (Legal Business Name): A.W.C. FAIRCLOUGH MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 UNIVERSITY DR SUITE 107
PONTIAC MI
48342-1885
US

IV. Provider business mailing address

989 UNIVERSITY DR SUITE 107
PONTIAC MI
48342-1885
US

V. Phone/Fax

Practice location:
  • Phone: 248-334-4773
  • Fax: 248-334-8230
Mailing address:
  • Phone: 248-334-4773
  • Fax: 248-334-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAF036119
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberAF036119
License Number StateMI

VIII. Authorized Official

Name: DR. ANTHONY FARICLOUGH
Title or Position: PRESIDENT
Credential: MD
Phone: 248-334-4773