MEDICARE: DR. JEFFREY EDWARD FANTICH D.C.

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	111N00000X	Chiropractor	2301006930	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	461982008	OTHER	MI	TAX ID
2	0F35177	OTHER	MI	BC PIN

General Provider Information

NPI Number	:	1386784692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY EDWARD FANTICH D.C.

Provider Business Mailing Address
First Line	:	5829 W MAPLE RD
Second Line	:	SUITE 123
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2294
Country	:	US
Telephone Number	:	248-737-8066
Fax Number	:	248-737-9093

Provider Business Practice Location Address
First Line	:	5829 W MAPLE RD
Second Line	:	SUITE 123
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2294
Country	:	US
Telephone Number	:	248-737-8066
Fax Number	:	248-737-9093

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	02/26/2013

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