Provider Demographics
NPI:1306142161
Name:ANTHONY J FAVA, MD PC
Entity type:Organization
Organization Name:ANTHONY J FAVA, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-832-4051
Mailing Address - Street 1:1425 GREENBRIER DEAR RD
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-8706
Mailing Address - Country:US
Mailing Address - Phone:256-832-4051
Mailing Address - Fax:256-832-4092
Practice Address - Street 1:1425 GREENBRIER DEAR RD
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-8706
Practice Address - Country:US
Practice Address - Phone:256-832-4051
Practice Address - Fax:256-832-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL14852261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009918040Medicaid
AL000051103Medicare PIN
ALC-36368Medicare UPIN