Provider Demographics
NPI:1275249898
Name:FANOUS CLINIC MEDICAL GROUP PC
Entity type:Organization
Organization Name:FANOUS CLINIC MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-224-7288
Mailing Address - Street 1:10926 S TRYON ST STE D
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4154
Mailing Address - Country:US
Mailing Address - Phone:980-224-7288
Mailing Address - Fax:800-507-2885
Practice Address - Street 1:10926 S TRYON ST STE D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4154
Practice Address - Country:US
Practice Address - Phone:980-224-7288
Practice Address - Fax:800-507-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty