Healthcare Provider Details

I. General information

NPI: 1174503023
Provider Name (Legal Business Name): JEAN K FAHEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEAN WEAVER MD

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 30TH AVENUE WEST ALEXANDRIA CLINIC PA
ALEXANDRIA MN
56308
US

IV. Provider business mailing address

610 30TH AVENUE WEST ALEXANDRIA CLINIC PA
ALEXANDRIA MN
56308
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-5123
  • Fax: 320-763-7883
Mailing address:
  • Phone: 320-763-5123
  • Fax: 320-763-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24716
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: