Basic Information
| Provider Information | |||||||||
| NPI: | 1053510446 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FADI SALLOUM MD PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IMPACT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483030869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482670135 | ||||||||
| FaxNumber: | 2483385547 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N PERRY ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483422217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483385516 | ||||||||
| FaxNumber: | 2483385547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALLOUM | ||||||||
| AuthorizedOfficialFirstName: | FADI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2482670135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301065435 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | OP46550 | 01 | MI | MEDICARE GROUP # | OTHER |