Basic Information
| Provider Information | |||||||||
| NPI: | 1174503023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEAVER | ||||||||
| OtherFirstName: | JEAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 610 30TH AVENUE WEST | ||||||||
| Address2: | ALEXANDRIA CLINIC PA | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVENUE WEST | ||||||||
| Address2: | ALEXANDRIA CLINIC PA | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 24716 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.