MEDICARE: MERCER ISLAND FAMILY MEDICINE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OP00002196	WA

General Provider Information

NPI Number	:	1194928697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCER ISLAND FAMILY MEDICINE, PLLC

Provider Business Mailing Address
First Line	:	54196 KATHERINE WOOD DR
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-2315
Country	:	US
Telephone Number	:	586-850-4645
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 ISLAND CREST WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-2998
Country	:	US
Telephone Number	:	586-850-4645
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SCOTT EDWARD FANNIN
Credential	:	D.O.
Telephone Number	:	586-850-4645

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	08/22/2020

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