Basic Information
| Provider Information | |||||||||
| NPI: | 1316997588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAYEK | ||||||||
| FirstName: | MARIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 DUDLEY STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 DUDLEY STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157625181 | ||||||||
| FaxNumber: | 2157625176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/06/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 001959988 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD13013 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | MD13013 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001959988 | 05 | PA | MEDICAID |