Basic Information
| Provider Information | |||||||||
| NPI: | 1720349210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FACIONE | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Practice Location | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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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 | 207R00000X | 5101020006 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1720349210 | 05 | MI | MEDICAID |