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General NPI Number Information
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NPI Number | 1770016453
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Entity Type | Individual
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Provider Name | JEREMIAH DOUGLAS FAIRBANKS DO
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Gender | Male
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Dates
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Enumeration Date | 04/09/2017
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Last Update Date | 02/01/2024
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Provider Practice Location Address
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Address Line | 1880 N FRONTAGE RD
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City | HASTINGS
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State | MN
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Zip | 55033-2687
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Country | US
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Telephone | 651-438-1880
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Fax |
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Provider Business Mailing Address
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Address Line | 1880 N FRONTAGE RD
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City | HASTINGS
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State | MN
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Zip | 55033-2687
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Country | US
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Telephone | 651-438-1800
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 64281
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 64281
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License Number State | MN
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