Basic Information
| Provider Information | |||||||||
| NPI: | 1417903998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARES | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 824665 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191822514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6097372223 | ||||||||
| FaxNumber: | 6097372350 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 WASHINGTON CROSSING RD | ||||||||
| Address2: | SUITE1 | ||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6097372223 | ||||||||
| FaxNumber: | 6097372350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MA039515 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0980581002 | 01 | NJ | CIGNA | OTHER | 1828703 | 05 | NJ | MEDICAID | 33697 | 01 | NJ | AETNA | OTHER |