Provider Demographics
NPI:1104144526
Name:A.W.C. FAIRCLOUGH MD PC
Entity type:Organization
Organization Name:A.W.C. FAIRCLOUGH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARICLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-334-4773
Mailing Address - Street 1:989 UNIVERSITY DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1885
Mailing Address - Country:US
Mailing Address - Phone:248-334-4773
Mailing Address - Fax:248-334-8230
Practice Address - Street 1:989 UNIVERSITY DR
Practice Address - Street 2:SUITE 107
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1885
Practice Address - Country:US
Practice Address - Phone:248-334-4773
Practice Address - Fax:248-334-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF036119207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0637997OtherBCBS
MI0637997OtherBCBS
MI0637977Medicare PIN