Provider Demographics
NPI:1487602876
Name:FANNON, MICHAEL SHAWN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:FANNON
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 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-805-0488
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:8260 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-764-6611
Practice Address - Fax:804-764-6562
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057920207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006713785Medicare PIN
VA110008052Medicare PIN
VA003002V21Medicare PIN
VA006713807Medicare PIN
VA014831C96Medicare PIN
VA011539V20Medicare PIN
VA006713823Medicare PIN