Healthcare Provider Details

I. General information

NPI: 1174553747
Provider Name (Legal Business Name): SCOTT J FAIRBAIRN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BROADWAY ST NE STE 300
MINNEAPOLIS MN
55413-1761
US

IV. Provider business mailing address

3433 BROADWAY ST NE STE 300
MINNEAPOLIS MN
55413-1761
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7737
  • Fax: 763-587-7069
Mailing address:
  • Phone: 763-587-7737
  • Fax: 763-587-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number36278
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: