Basic Information
| Provider Information | |||||||||
| NPI: | 1396735585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIDIAS | ||||||||
| FirstName: | PANAGIOTIS | ||||||||
| MiddleName: | MIHALIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024068222 | ||||||||
| FaxNumber: | 6024066292 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024068222 | ||||||||
| FaxNumber: | 6024066292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 77854 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | 77854 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | 49332 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3188001 | 05 | MA | MEDICAID | J19643 | 01 | MA | BCBS MA | OTHER | 077854 | 01 | MA | TUFTS HEALTH PLAN | OTHER |