Healthcare Provider Details

I. General information

NPI: 1619974730
Provider Name (Legal Business Name): FAYE MICHELLE IMM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MEDICAL DR SUITE A
LIMA OH
45804-4099
US

IV. Provider business mailing address

801 MEDICAL DR SUITE A
LIMA OH
45804-4031
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-6622
  • Fax: 419-224-0015
Mailing address:
  • Phone: 419-222-6622
  • Fax: 419-224-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.002222
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000521052
Identifier TypeOTHER
Identifier State
Identifier IssuerANTHEM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: