Provider Demographics
NPI:1487092391
Name:FAZENDIN, EDWARD ANDREW (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANDREW
Last Name:FAZENDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3686 GRANDVIEW PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3404
Mailing Address - Country:US
Mailing Address - Phone:205-595-8985
Mailing Address - Fax:205-595-8987
Practice Address - Street 1:3686 GRANDVIEW PKWY STE 400
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3404
Practice Address - Country:US
Practice Address - Phone:205-595-8985
Practice Address - Fax:205-595-8987
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT204318208600000X
AL38369208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL256202Medicaid