MEDICARE: MARK FAIRCHILD PAC

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	363AM0700X	Medical Physician Assistant	PA434	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255304598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK FAIRCHILD PAC

Provider Business Mailing Address
First Line	:	PO BOX 550
Second Line	:
City	:	VANCEBURG
State	:	KY
Zip	:	41179-0550
Country	:	US
Telephone Number	:	606-796-3029
Fax Number	:	606-796-6221

Provider Business Practice Location Address
First Line	:	211 KY 59
Second Line	:
City	:	VANCEBURG
State	:	KY
Zip	:	41179-9701
Country	:	US
Telephone Number	:	606-796-3029
Fax Number	:	606-796-6221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	06/24/2010

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Directions to “ MARK FAIRCHILD PAC” Practice Location

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