Healthcare Provider Details

I. General information

NPI: 1720349210
Provider Name (Legal Business Name): BRIAN FACIONE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 CLEVELAND AVE SUITE 5
STEVENSVILLE MI
49127-9670
US

IV. Provider business mailing address

5515 CLEVELAND AVE SUITE 5
STEVENSVILLE MI
49127-9670
US

V. Phone/Fax

Practice location:
  • Phone: 269-429-9644
  • Fax: 269-429-4002
Mailing address:
  • Phone: 269-429-9644
  • Fax: 269-429-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101020006
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: