Provider Demographics
NPI:1053510446
Name:FADI SALLOUM MD PC
Entity Type:Organization
Organization Name:FADI SALLOUM MD PC
Other - Org Name:IMPACT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:SALLOUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-267-0135
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48303-0869
Mailing Address - Country:US
Mailing Address - Phone:248-267-0135
Mailing Address - Fax:248-338-5547
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5516
Practice Address - Fax:248-338-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP46550OtherMEDICARE GROUP #
MIP46550001Medicare PIN