Provider Demographics
NPI:1174106652
Name:MADONNA FABIAN MD PC
Entity type:Organization
Organization Name:MADONNA FABIAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DEGREE
Authorized Official - Phone:323-547-2155
Mailing Address - Street 1:7320 STEVENSVILLE BARODA RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9703
Mailing Address - Country:US
Mailing Address - Phone:323-547-2155
Mailing Address - Fax:
Practice Address - Street 1:3078 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8608
Practice Address - Country:US
Practice Address - Phone:323-547-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty