Basic Information
Provider Information | |||||||||
NPI: | 1982633178 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANI SROUR | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60447 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282600447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048874530 | ||||||||
FaxNumber: | 7048874531 | ||||||||
Practice Location | |||||||||
Address1: | 10030 GILEAD RD STE 201 | ||||||||
Address2: |   | ||||||||
City: | HUNTERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 28078 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048874530 | ||||||||
FaxNumber: | 7048874531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2006 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 2019-01351 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 13064 | NH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 13064 | NH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 2019-01351 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 1170828 | 01 | NH | CIGNA | OTHER | 396965 | 01 | NH | MVP | OTHER | 432327299 | 05 | ME |   | MEDICAID | 7984888 | 01 | NH | AETNA | OTHER | AA73407 | 01 | NH | HARVARD PILGRIM | OTHER | 01Y010853NH02 | 01 | NJ | BCBS | OTHER | 30206253 | 05 | NH |   | MEDICAID | 5761654 | 01 | NH | FIRST HEALTH | OTHER |