Basic Information
| Provider Information | |||||||||
| NPI: | 1780899567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAULK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WELLINGTON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 CRESCENT PARK WEST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147232510 | ||||||||
| FaxNumber: | 8147234654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CRESCENT PARK WEST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147232510 | ||||||||
| FaxNumber: | 8147234654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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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 | 207P00000X | MD432033 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000543098 | 01 | OH | ANTHEM | OTHER | N424355 | 01 | OH | NON PAR WELLCARE | OTHER | 2770014 | 05 | OH | MEDICAID | 1019333580004 | 05 | PA | MEDICAID |