Provider Demographics
NPI:1316997588
Name:FAYEK, MARIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:FAYEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DUDLEY STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:101 DUDLEY STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:215-762-5181
Practice Address - Fax:215-762-5176
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA001959988207R00000X
RIMD13013207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001959988Medicaid
H89934Medicare UPIN