Basic Information
| Provider Information | |||||||||
| NPI: | 1326007865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANOUS-PAUL | ||||||||
| FirstName: | AMIRA | ||||||||
| MiddleName: | BOULOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300764915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707512500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707512500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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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 | 207ZP0105X | 38616 | KY | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | 77475 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 177879701 | 05 | TX | MEDICAID |