Basic Information
| Provider Information | |||||||||
| NPI: | 1962440081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRFAX | ||||||||
| FirstName: | MARILYNN | ||||||||
| MiddleName: | RANSOM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815974 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 ST ANTOINE | ||||||||
| Address2: | UHC 3C | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | 4301058560 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZM0300X | 4301058560 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology |
No ID Information.