MEDICARE: DENNIS L. FAST MD INC

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	01028579A	IN

General Provider Information

NPI Number	:	1629335716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENNIS L. FAST MD INC

Provider Business Mailing Address
First Line	:	350 JH WALKER DR
Second Line	:	SUITE 110
City	:	PENDLETON
State	:	IN
Zip	:	46064-8750
Country	:	US
Telephone Number	:	765-622-0003
Fax Number	:	765-778-7535

Provider Business Practice Location Address
First Line	:	350 JH WALKER DR
Second Line	:	SUITE 110
City	:	PENDLETON
State	:	IN
Zip	:	46064-8750
Country	:	US
Telephone Number	:	765-622-0003
Fax Number	:	765-778-7535

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENNIS LEE FAST
Credential	:	M.D.
Telephone Number	:	765-622-0003

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	04/13/2012

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