Provider Demographics
NPI:1982880647
Name:ELIAS I FANOUS JR MD PA
Entity type:Organization
Organization Name:ELIAS I FANOUS JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:I
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:903-526-3030
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:SUITE 508
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1951
Mailing Address - Country:US
Mailing Address - Phone:903-526-3030
Mailing Address - Fax:
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:SUITE 508
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-526-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8030207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF80332Medicare UPIN
TX00494TMedicare PIN