Provider Demographics
NPI:1699112607
Name:FAHNHORST, SARAH ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:FAHNHORST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 4200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2559
Practice Address - Country:US
Practice Address - Phone:616-267-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-141190207R00000X, 208000000X
MI51010269442080P0202X, 207RA0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036141190Medicaid