1215973565 NPI number — MICHAEL S FAKHRAEE MD

Table of content: MICHAEL S FAKHRAEE MD (NPI 1215973565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215973565 NPI number — MICHAEL S FAKHRAEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAKHRAEE
Provider First Name:
MICHAEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215973565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19111-2431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-728-8200
Provider Business Mailing Address Fax Number:
215-725-3209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-728-8200
Provider Business Practice Location Address Fax Number:
215-725-3209
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2082S0105X , with the licence number:  MD018776E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 400138 . This is a "BLUE CROSS &BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0052487000 . This is a "KEYSONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 400138 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 400138 . This is a "FEDERAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com