Healthcare Provider Details

I. General information

NPI: 1023645694
Provider Name (Legal Business Name): STEPHANIE FABRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 COLUMBIA RD STE 102
WESTLAKE OH
44145-1461
US

IV. Provider business mailing address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

V. Phone/Fax

Practice location:
  • Phone: 440-808-1925
  • Fax:
Mailing address:
  • Phone: 216-844-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.147421
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: