Basic Information
| Provider Information | |||||||||
| NPI: | 1013909837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FATH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193837146 | ||||||||
| FaxNumber: | 4193832050 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139825440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 4301051219 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 465852010 | 05 | MI | MEDICAID | 4301051219 | 01 | MI | CONTROLLED SUSBSTANCE | OTHER | AF1642126 | 01 | MI | FEDERAL DEA | OTHER |