Basic Information
| Provider Information | |||||||||
| NPI: | 1114376043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALLAHI | ||||||||
| FirstName: | IMANEH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVENUE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 ST PAUL DR | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172176820 | ||||||||
| FaxNumber: | 7178392768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | MD472136 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 103909558 | 05 | PA | MEDICAID | 15141331 | 01 | CAQH | OTHER |