Basic Information
| Provider Information | |||||||||
| NPI: | 1205193422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANOUSE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 453 EMERSON LN | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188643892 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4802 10TH AVE | ||||||||
| Address2: | MAIMONIDES MEDICAL CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182836000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 25MB10005200 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.