Basic Information
| Provider Information | |||||||||
| NPI: | 1558598292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANOUS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAROBEEM | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | RED LION & KNIGHTS ROADS | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | 2159497806 | ||||||||
| Practice Location | |||||||||
| Address1: | RED LION & KNIGHTS ROADS | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | 2159497806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2009 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OT012883 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | OT012883 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | OT012883&OS015355 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | OS015355&OT012883 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.