Basic Information
| Provider Information | |||||||||
| NPI: | 1326390600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2660 W MARKET ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443334208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308692635 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2660 W MARKET ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443334208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308692635 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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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 | 2255A2300X | AT-001585 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.