Provider Demographics
NPI:1033183801
Name:FAHIM, FAHIM (MD)
Entity Type:Individual
Prefix:
First Name:FAHIM
Middle Name:
Last Name:FAHIM
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 1:301 ELM AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4001
Mailing Address - Country:US
Mailing Address - Phone:540-345-9841
Mailing Address - Fax:540-527-2900
Practice Address - Street 1:3517 BRANDON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1523
Practice Address - Country:US
Practice Address - Phone:540-981-1102
Practice Address - Fax:540-344-4169
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012317722084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA081024OtherSENTARA
VA2182262OtherCIGNA
VA246008OtherHEALTHKEEPERS
VA004945263Medicaid
VA246008OtherANTHEM
VA537848000OtherMEGALLAN
VA4945263OtherVIGINIA PREMIER