MEDICARE: DR. SCOTT EDWARD FANNIN D.O.

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	5101016126	MI
2	207Q00000X	Family Medicine Physician	OP00002196	WA

General Provider Information

NPI Number	:	1467547760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT EDWARD FANNIN D.O.

Provider Business Mailing Address
First Line	:	3003 ISLAND CREST WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-2998
Country	:	US
Telephone Number	:	206-275-3487
Fax Number	:	206-275-3486

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	:	206-275-3487
Fax Number	:	206-275-3486

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/29/2007

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