Provider Demographics
NPI:1194928697
Name:MERCER ISLAND FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:MERCER ISLAND FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-850-4645
Mailing Address - Street 1:54196 KATHERINE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-2315
Mailing Address - Country:US
Mailing Address - Phone:586-850-4645
Mailing Address - Fax:
Practice Address - Street 1:3003 ISLAND CREST WAY
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2998
Practice Address - Country:US
Practice Address - Phone:586-850-4645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty