Basic Information
| Provider Information | |||||||||
| NPI: | 1457735326 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS PARTNERS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ORLANDO NEUROSURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4079750209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4079750209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAWIN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4079750200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 015390400 | 05 | FL | MEDICAID |