Provider Demographics
NPI:1386868875
Name:FADI G. GHANEM, MD PA
Entity type:Organization
Organization Name:FADI G. GHANEM, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:G
Authorized Official - Last Name:GHANEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-419-1599
Mailing Address - Street 1:PO BOX 7727
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77387-7727
Mailing Address - Country:US
Mailing Address - Phone:281-419-1599
Mailing Address - Fax:281-898-7632
Practice Address - Street 1:1111 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 230
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3476
Practice Address - Country:US
Practice Address - Phone:281-419-1599
Practice Address - Fax:281-898-7632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8071207Q00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0806481-01Medicaid
TX00013DMOtherBCBS GROUP
TX00468KMedicare PIN