Basic Information
| Provider Information | |||||||||
| NPI: | 1093700932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHANEM | ||||||||
| FirstName: | FADI | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7727 | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773807727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814191599 | ||||||||
| FaxNumber: | 2818987632 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814191599 | ||||||||
| FaxNumber: | 2818987632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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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 | 207Q00000X | H8071 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | H8071 | TX | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 139600417 | 01 | TX | EPSDT | OTHER | 83900X | 01 | TX | BCBS OF TX | OTHER | 139600406 | 05 | TX | MEDICAID |