Basic Information
| Provider Information | |||||||||
| NPI: | 1538268438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAITEH | ||||||||
| FirstName: | FADI | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N STEPHANIE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523350 | ||||||||
| FaxNumber: | 7029523365 | ||||||||
| Practice Location | |||||||||
| Address1: | 3730 S EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523400 | ||||||||
| FaxNumber: | 7029523460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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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 | 174400000X | 4301095414 | MI | N | Other Service Providers | Specialist | 207R00000X | L9109 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 4301095414 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 13623 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 177195801 | 05 | TX | MEDICAID | 0410515 | 01 | MI | BCBSM PIN | OTHER | P00754153 | 01 | MI | RR MEDICARE | OTHER |