1780850974 NPI number — SALAH FARES MD

Table of content: SALAH FARES MD (NPI 1780850974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780850974 NPI number — SALAH FARES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARES
Provider First Name:
SALAH
Provider Middle Name:
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:
1780850974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 MEDICAL PLAZA DRIVE
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77380-3477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-296-8788
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27211 LAHSER RD
Provider Second Line Business Practice Location Address:
STE # 200
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-8469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-358-4982
Provider Business Practice Location Address Fax Number:
248-358-5125
Provider Enumeration Date:
05/07/2008

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: 207RP1001X , with the licence number:  Q3670 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346398971 . This is a "GRP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11-0F33636-0 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301087647 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20-5485614 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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