Provider Demographics
NPI:1114376043
Name:FALLAHI, IMANEH (MD)
Entity Type:Individual
Prefix:
First Name:IMANEH
Middle Name:
Last Name:FALLAHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 5TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:12 ST PAUL DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1035
Practice Address - Country:US
Practice Address - Phone:717-217-6820
Practice Address - Fax:717-839-2768
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
PAMD472136207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103909558Medicaid
15141331OtherCAQH