Basic Information
| Provider Information | |||||||||
| NPI: | 1629069364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43201 COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862864430 | ||||||||
| FaxNumber: | 5862864727 | ||||||||
| Practice Location | |||||||||
| Address1: | 43201 COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107944982 | ||||||||
| FaxNumber: | 8107944407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301050703 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2889752 | 05 | MI | MEDICAID |