Basic Information
| Provider Information | |||||||||
| NPI: | 1497109219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAYBUSOVICH | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR STE 1325 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543650 | ||||||||
| FaxNumber: | 3206543681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR STE 1325 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543650 | ||||||||
| FaxNumber: | 3206543681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2016 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | OT019251 | PA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207R00000X | OS020058 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.