1376523902 NPI number — JOSEPH B FARES MD

Table of content: JOSEPH B FARES MD (NPI 1376523902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376523902 NPI number — JOSEPH B FARES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARES
Provider First Name:
JOSEPH
Provider Middle Name:
B
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:
1376523902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W UTOPIA RD
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-214-6148
Provider Business Mailing Address Fax Number:
602-214-6149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18404 N TATUM BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85032-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-580-5390
Provider Business Practice Location Address Fax Number:
623-580-5397
Provider Enumeration Date:
01/19/2006

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: 207RG0100X , with the licence number:  25MA06825900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2Z3840 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 100919 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZP00349542 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7272302 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ042595910 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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