Basic Information
Provider Information
NPI: 1386868875
EntityType: 2
ReplacementNPI:  
OrganizationName: FADI G. GHANEM, MD PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: MATERNAL AND FAMILY CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 7727
Address2:  
City: SPRING
State: TX
PostalCode: 773877727
CountryCode: US
TelephoneNumber: 2814191599
FaxNumber: 2818987632
Practice Location
Address1: 1111 MEDICAL PLAZA DR
Address2: SUITE 230
City: THE WOODLANDS
State: TX
PostalCode: 773803476
CountryCode: US
TelephoneNumber: 2814191599
FaxNumber: 2818987632
Other Information
ProviderEnumerationDate: 04/13/2007
LastUpdateDate: 08/18/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GHANEM
AuthorizedOfficialFirstName: FADI
AuthorizedOfficialMiddleName: G
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 2814191599
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
291U00000XH8071TXN LaboratoriesClinical Medical Laboratory 
207Q00000XH8071TXY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
0806481-0105TX MEDICAID
00013DM01TXBCBS GROUPOTHER


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