Provider Demographics
NPI:1386698462
Name:THALJEH, FAISAL (MD)
Entity type:Individual
Prefix:DR
First Name:FAISAL
Middle Name:
Last Name:THALJEH
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:301 W BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3427
Practice Address - Country:US
Practice Address - Phone:318-747-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14353R207P00000X
LAMD.14353R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00979659OtherRRMCARE THRU GPN MANY
LA1049077Medicaid
LA4E251DD04Medicare PIN
LAF94468Medicare UPIN
LA1049077Medicaid
LA4E251CR06Medicare PIN