Provider Demographics
NPI:1215973565
Name:FAKHRAEE, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:FAKHRAEE
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 1:7500 CENTRAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2431
Mailing Address - Country:US
Mailing Address - Phone:215-728-8200
Mailing Address - Fax:215-725-3209
Practice Address - Street 1:7500 CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2431
Practice Address - Country:US
Practice Address - Phone:215-728-8200
Practice Address - Fax:215-725-3209
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018776E2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA400138OtherBLUE CROSS &BLUE SHIELD
PA0052487000OtherKEYSONE HEALTH PLAN EAST
PA400138OtherPERSONAL CHOICE
PA400138OtherFEDERAL BLUE CROSS
PA400138Medicare PIN