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General NPI Number Information
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NPI Number | 1174106652
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Entity Type | Organization
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Legal Business Name | MADONNA FABIAN MD PC
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Dates
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Enumeration Date | 05/03/2021
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Last Update Date | 05/18/2021
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Provider Practice Location Address
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Address Line | 3078 NILES RD
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-8608
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Country | US
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Telephone | 323-547-2155
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Fax |
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Provider Business Mailing Address
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Address Line | 7320 STEVENSVILLE BARODA RD
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City | STEVENSVILLE
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State | MI
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Zip | 49127-9703
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Country | US
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Telephone | 323-547-2155
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MADONNA FABIAN
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Credential | MEDICAL DEGREE
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Telephone | 323-547-2155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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