Provider Demographics
NPI:1215922109
Name:FADLALLAH, HOUSSAM M (PA-C)
Entity type:Individual
Prefix:
First Name:HOUSSAM
Middle Name:M
Last Name:FADLALLAH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 SCHAEFER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1813
Mailing Address - Country:US
Mailing Address - Phone:313-584-7900
Mailing Address - Fax:313-584-4411
Practice Address - Street 1:6500 SCHAEFER RD
Practice Address - Street 2:SUITE A
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-584-7900
Practice Address - Fax:313-584-4411
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P83648Medicare UPIN
MIP28070055Medicare ID - Type Unspecified