Provider Demographics
NPI:1093700932
Name:GHANEM, FADI G (MD)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:G
Last Name:GHANEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7727
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-7727
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:77380-3477
Practice Address - Country:US
Practice Address - Phone:281-419-1599
Practice Address - Fax:281-898-7632
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8071207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139600417OtherEPSDT
TX83900XOtherBCBS OF TX
TX139600406Medicaid
TX139600406Medicaid
TX139600417OtherEPSDT