Provider Demographics
NPI:1114114014
Name:GHANNAM, DANY EDWARD (MD)
Entity type:Individual
Prefix:
First Name:DANY
Middle Name:EDWARD
Last Name:GHANNAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-946-4611
Mailing Address - Fax:509-942-2185
Practice Address - Street 1:888 SWIFT BLVD.
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:509-942-2785
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048902207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA025904OtherL&I KRMC GROUP NUMBER
WA1114114014Medicaid
WA1114114014Medicaid