Healthcare Provider Details

I. General information

NPI: 1497109219
Provider Name (Legal Business Name): PAUL FAYBUSOVICH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR STE 1325
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR STE 1325
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3650
  • Fax: 320-654-3681
Mailing address:
  • Phone: 320-654-3650
  • Fax: 320-654-3681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberOT019251
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS020058
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: