Basic Information
| Provider Information | |||||||||
| NPI: | 1447293840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIN | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722340813 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W 38TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124199733 | ||||||||
| FaxNumber: | 5124513709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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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 | 207RH0003X | H4310 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8BP225 | 01 | TX | BCBS OF TX | OTHER | P00645999 | 01 | TX | RAILROAD MEDICARE | OTHER | 131313207 | 05 | TX | MEDICAID | 131313202 | 05 | TX | MEDICAID | 830004599 | 01 | TX | RAILROAD MEDICARE NUMBER | OTHER | 131313208 | 05 | TX | MEDICAID |